1.

0 INTRODUCTION

1.1 introduction

We shall begin the first lecture by introducing the life-cycle and intergenerational nature of
malnutrition. We will then look at the vulnerable points in the life cycle and the essential nutrition
actions that support good nutrition outcomes. The lecture will then end with recommendations for daily
intake as outlined in the food pyramid.

1.2 lecture objectives

By the end of this lecture, you should be able to:

Describe the life-cycle and intergenerational nature of nutrition

 Outline the nutritional recommendations as given in the food pyramid

 List the stages in the lifecycle that are vulnerable to malnutrition

1.3 The life-cycle and intergenerational nature of nutrition

Chronic under-nutrition resulting from poor foetal growth and growth deficits in 0-2 years is like a “life
sentence”. Together with under-nutrition in childhood and adolescence, it has a cumulative negative
impact. A fetus that has suffered intrauterine growth retardation (IUGR) is born malnourished and has a
higher risk of dying within the first year after birth. Those that survive are more likely to have deficits
in growth and development, carry on the malnutrition throughout life, and more likely to be ill,
compared to their well-nourished peers. If their diet does not improve, they are likely to enter and stay
in childhood stunted and underweight. A child who is stunted at five years of age is likely to remain
stunted throughout life.

Fig 1.1: Under-nutrition throughout the life cycle

Adolescence, a second period of rapid growth, offers a limited window of opportunity for
compensating for growth failure in early childhood. However, even if the child catches up on some lost
growth, the effects of early childhood under-nutrition on cognitive development and behavior may not
be fully reversed.

If the stunted child is a girl, she is likely to become a stunted adolescent and later a stunted adult. Apart
from direct effects on her health and productivity, adult stunting and underweight increase the chance
that her children will be born with low birth weight. Moreover, in areas of poverty and limited
opportunities, she is likely to get pregnant early as an adolescent, increasing the chance of both her and
her babies being malnourished. This cycle repeats itself from one generation to the next.

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If the stunted child is a boy, he is likely to grow into an adult with limited opportunities in life due to
reduced potential. He is likely to be shorter in height, and have reduced cognitive and physical abilities
thus becoming less economically productive. In addition, he is likely to start a family with an also
malnourished girl. This makes it hard to rise out of poverty and hunger. Their children will grow in this
limiting environment and are thus also at risk for malnutrition, and the cycle repeats itself from one
generation to the next. You can see that under-nutrition is intergenerational and early malnutrition
affects an individual throughout their life

1.4 Vulnerable stages in the life-cycle

 Foetal stage (-9 to 0 months): intra-uterine nutrition impacts on birth weight and micronutrient
stores after birth e.g. calories, iron, iodine and Vitamin A
 Infancy: Depending on feeding practices and other environmental factors that influence
childcare and childhood illnesses’ prevalence, severity and re-occurrence. This can also
influence survival of the infant.
 Young childhood (Under five years): Depending on feeding practices and other environmental
those influence childcare and childhood illnesses’ prevalence, severity and re-occurrence. This
can also influence child survival.
 Women of reproductive age (beginning with adolescents): Women of reproductive age are
particularly vulnerable due to the nutrient losses they face through monthly menses,
pregnancies, deliveries and lactation. Women of this age, especially in resource limited settings
are also usually involved in energy demanding activities in their daily life. The problem is
compounded by food insecurity and poverty which means that the body is mostly under-
nourished and cannot match its nutrient needs.
 Pregnant women: The woman may get into pregnancy already malnourished (underweight and
micro-nutrient deficiencies). She has now to share her already low nutrient stores with the
foetus. This can lead to depletion of these stores and/ or deficiencies, especially if there is no
improvement in the dietary intake.
 Lactating women: If the woman gets into lactation and breastfeeding after pregnancy already
malnourished (underweight and micro-nutrient deficiencies), it could lead to further depletion of
her nutrient stores and/ or deficiencies, especially if there is no improvement in her dietary
intake.
 The elderly due to the fact that most of them have reduced physical functioning and
interventions do not target them.

1.5 Essential nutrition actions

As you may have realized by now, women and children are particularly vulnerable to malnutrition.
There is need to initiate interventions that focus on the essential nutrition actions to protect, promote,
and support the following priority nutrition outcomes as suggested by UNICEF:

 Exclusive breastfeeding for at least six months

 Adequate complementary feeding starting at about six months with continued breastfeeding for
two years

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  Appropriate nutritional care of sick and malnourished children
 Adequate intake of vitamin A for women and children
 Adequate intake of iron for women and children
 Adequate intake of iodine by all members of the household.

These can be achieved through nutrition interventions like nutrient supplementation, food aid, food
fortification, nutrition education and promotion, and food security programs among others.

1.6 Good nutrition as a way of life

By now, you know that good nutrition is important throughout life, especially in the early stages. It is
thus recommended to make good nutrition part of our lifestyle, throughout our life. A good nutritional
status is achieved from a diet rich in nutrients that meet our requirements. To guide us on how to
achieve this is the food pyramid which summarizes the daily recommendations.

From the pyramid, the recommendations are that, everyday, we should:

 Take adequate amounts of fluids- 8 glasses of water

 Ensure half the grains consumed are whole e.g. oatmeal, whole-wheat flour, whole maize meal,
brown rice, and whole-wheat bread.
 Choose a variety of vegetables, including dark green and orange colored ones, legumes (peas
and beans), starchy vegetables, and other vegetables.
 Focus on fruits, preferably fresh, although canned, frozen, or dried also counts. The fruit may be
whole, chopped or pureed.
 Get calcium-rich foods. Milk and milk products contain calcium and vitamin D, both important
ingredients in building and maintaining bone tissue.
 Take lean or low fat meats and poultry. Vary your protein by taking fish, nuts, seeds, peas, and
beans.
 Limit fats, sugars, and salt (sodium). Make most of your fat sources from fish, nuts, and
vegetable oils. Limit solid fats like butter, margarine, shortening, and foods that contain these.
 Include nutrient supplements when necessary e.g folate in pregnancy or during specific
deficiencies

1.7 summary

In this lecture, we learnt that:

 Nutritional status is a cumulative result of dietary habits

 Malnutrition can be perpetuated through generations if dietary intake does not improve
 The fetus, infants, children aged less than 5 years, adolescent girls, pregnant and lactating
women are the most vulnerable to malnutrition

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1.8 activities

Compare the nutritional recommendations of the food pyramid to the food wheel.

1.9 further reading

Martorell R, Ramakrishnan U, Schroeder DG, Melgar P, Neufeld L (1998) Intrauterine growth

retardation, body size, body composition and physical performance in adolescence. European Journal
of Clinical Nutrition 52: S43-S53.

1.10 Self-test: 1

To test how well you have understood this lecture, answer each of the following questions. Each
question is worth 1 mark.

1. Describe the life-cycle and intergenerational nature of nutrition

2. Outline the nutritional recommendations as given in the food pyramid
3. List the stages in the lifecycle that are vulnerable to malnutrition
4. Discuss the link between malnutrition and poverty
5. The two “windows of opportunity” in improving nutritional status are ____________ and
___________________

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 2.0 NUTRITION DURING THE PRE-CONCEPTION PERIOD

2.1 introduction

We will now begin with nutrition during the pre-conception period. This is because adequate nutrition
before conception has the potential to have long-term health impacts on both the mother and the yet to
be conceived child. It helps ensure that the baby has an optimal environment to grow in, and reduces
the chances of deficiencies that may result in birth defects. In addition, it improves fertility and the
chances of conception. It is recommended that both the male and female focus on good nutrition, a
healthy lifestyle and increased fitness, at least 6 months prior to conception. This will help to optimize
the sperm quality and quantity, and prepare the female body for a successful pregnancy and delivery. A
woman planning to conceive should evaluate whether or not she has enough nutrient stores to carry a
pregnancy for nine months. This underscores the importance of women making conscious decisions
about their reproductive health – when to have children and preparing the body to support the
pregnancies.

The general rule is to maintain a diet rich in fruits, vegetables, whole grains, lean meats, and dairy
products so as to meet the recommended dietary allowance of vitamins and minerals. Fluids are also
important, with recommendations of up to two litres of water daily - diluted fruit and vegetable juices
and herbal teas are also good sources of fluids. Another important element that is usually forgotten is
exercise. Keeping fit is vital for optimum health.

2.2 lecture objectives

By the end of this lecture, you should be able to:

 List the nutritional disorders common in women of reproductive age

 Explain the reasons for nutrition related pre-pregnancy considerations
 Identify nutrients that boost fertility
 Identify nutrients that favour a healthy pregnancy

2.3 Nutrition disorders in women of reproductive age

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Common nutrition disorders in women of reproductive age are:

 Vitamin A deficiency
 Iron deficiency
 Iodine deficiency disorders

Other disorders not common but are significant enough to mention are:

 Obesity
 Hypertension
 Diabetes
 Eating disorders
 Chronic energy malnutrition

2.4 Important nutrition related pre-pregnancy considerations

Pre-pregnancy weight

A woman's pre-pregnancy weight is directly related to her baby's birth weight. Pre-pregnancy body
mass index (BMI) is an important factor in predicting pregnancy outcome, since both low and high pre-
pregnancy BMI are associated with an increased risk for a negative pregnancy outcome. An
underweight woman is more likely to give birth to underweight babies, even if she gains the same
amount of weight in pregnancy as a normal weight woman. Pre-pregnancy weight also has an influence
on lactation. This is because the existing fat stores prior to pregnancy usually act as part of reserves for
milk production after delivery. This however, does not mean that women should be overweight before
getting pregnant, quite the contrary.

An overweight woman usually has an increased risk for complications like prolonged labour,
gestational diabetes and high blood pressure in pregnancy. Her baby is also usually at an increased risk
for being overweight and developing chronic diseases in their lifetime. In order to control body weight
and blood sugar, it is recommended that the woman increases her consumption of whole grains (brown
rice, oats, and whole wheat bread) pulses, legumes, fruits and vegetables to provide a nutrient dense
source of calories.

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Contraception

A good number of women usually use contraceptives as a form of birth control. These can sometimes
alter fertility when the woman decides to discontinue them and get pregnant. Some methods in
addition, have an impact on nutritional status since they usually interfere with nutrient absorption and
utilisation. Women using contraceptives (especially the hormonal types) therefore, should build
adequate stores of nutrients to counter their effects before getting pregnant.

Recent pregnancy

Recent pregnancies could have depleted the nutrient stores. Women thus need to space pregnancies so
as to build up enough nutrients for the anticipated pregnancy.

Eating disorders

Eating disorders like Anorexia nervosa, Bulimia nervosa and Binge eating disorders have an
implication on the nutrient stores of a woman. They also impact on the pre-pregnancy weight of the
woman. Women suffering from these disorders should thus be monitored and corrected for nutrient
levels before pregnancy.

2.5 Specific Nutrient Needs

We will start with nutrients that increase the chances of conceiving by boosting fertility.

Fibre: Intake of both soluble and insoluble fibre from oats, cereal bran, lentils, pulses, prunes, fruits
and vegetables is important. Fibre is important for blood sugar regulation and hormonal balance.

Magnesium: This is required for hormonal balance and resistance to stress. Foods rich in magnesium
include – Kales (Sukuma Wiki), broccoli, spinach, okra, peas, sunflower seeds, sesame seeds, almonds,
and lentils

Selenium: This is required for good ovarian health, sperm health and detoxification. Foods rich in
selenium include - onions, tomatoes, mushrooms, kidney beans, lentils, shrimp, prawns, lobster, crab,
sardines, mackerel, broccoli, kidney, brown rice, sesame seeds, sunflower seeds and cashew nuts

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Zinc: This is required for good sperm quality and quantity, hormonal balance and immunity. It plays a
role in the production of semen and testosterone in men, and in the ovulation and fertility in women.
The recommended dietary allowance of zinc is about 15 mg a day. Foods rich in Zinc include - peas,
tofu, chickpeas, prawns, squid, chicken, turkey, lean red meat, white fish, oats, brown rice, cashew
nuts, pumpkin seeds, crab, lobster and sardines.

Vitamin B6: This is important for hormonal balance and fertility. Foods rich in Vitamin B6 include -
cabbage, bananas, groundnuts, walnuts, sunflower seeds, green vegetables, pulses, eggs and tofu.

Vitamin E: This is essential for hormonal balance and fertility. Foods that provide vitamin E include -
most nuts, blackberries and sunflower oil

Fats: The omega 3 and omega 6 fatty acids found in nuts, seeds and oily fish are important for
hormonal balance and healthy sperm cells. Omega 3 fats are very important for brain development in
the third trimester and early infancy when women are breastfeeding their babies.

Protein: This is important for hormone production and proper cell production and growth. Intake of
high quality protein from chicken, fish and vegetable sources like lentils, pulses, nuts and seeds is
recommended.

We will now look at nutrients that are important for the optimal health of both the mother and the baby
(during and after pregnancy), and whose stores should be boosted before conception.

Folic acid: It is recommended that women of reproductive age obtain 400 micrograms (0.4 milligrams)
of folate or folic acid daily. Folic acid works closely with vitamin B12 and is required for the enzymes
that produce DNA for replicating and growing cells, including those of the gastrointestinal tract, blood,
and growing fetus. It is known to help reduce the risk of birth defects of the brain and spinal cord
(neural tube defects). The most common neural tube defect being spina bifida (where the vertebrae do
not fuse together properly, leaving the spinal cord exposed), which could result in varying degrees of
paralysis, incontinence, and mental retardation. In addition, it helps reduce the likelihood of recurrent
miscarriage, preterm delivery and low birth weight babies.

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Folic acid is most beneficial in the first month after conception, as this is when most neural tube defects
occur. It is important to remember that many women usually do not realize they are pregnant in the first
month. Moreover, many pregnancies are unplanned. Folic acid intake should therefore begin prior to
conception and continue through pregnancy. Better still, all women should take multivitamins, where
folic acid is included.

Foods rich in folic acid include legumes, peas, grain products and cereals, nuts, fruits and dark green
leafy vegetables. Even if a woman’s diet is composed of plenty of foods with Folate, only about 50 per
cent of this is available to the body, while the vitamin form is 100 per cent available. Cooking also
sometimes reduces the nutrient density in food. Some drugs (e.g. aspirin and oral contraceptives)
interfere with the absorption and metabolism of Folate. Supplementation is thus important. A prenatal
supplement however, does not replace a healthy diet.

Consequences of maternal folic acid deficiency

Impaired cell division

Megaloblastic anemia resulting from abnormal cell replication due to impaired DNA synthesis

Babies with neural tube defects such as anencephaly and spina bifida

Low birth weight babies

Iron: Iron intake is also vital for pregnancy. Before becoming pregnant, a woman will benefit from
boosting her iron stores. Many women have low iron stores because of the monthly menstruation and
diets low in iron. Building iron stores helps prepare a woman's body for the needs of the foetus during
pregnancy. Non-vegetarian women who are not pregnant need 18 mg of iron a day. Vegetarians need
even more, about 30 mg per day. Good quality sources of iron that can be incorporate into the diet
include meats, poultry, fish, leafy Greens and iron enriched grains and products such as cereals and
rice. Iron in plant foods is not usually well absorbed, so women should add a source of vitamin C such
as oranges or an animal protein, to enhance the absorption of the iron in plants. Iron supplementation
can help prevent and treat iron deficiency anemia, and boost the iron stores of a woman who is planning

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to get pregnant. Iron deficiency is the number one nutrient deficiency among women and should
therefore be taken seriously.

Causes of iron deficiency

 Low dietary iron intake

 Low bioavailability of dietary iron (e.g when the diet has high content of non-heme iron from
vegetable sources or when the diet has high content of iron inhibitors such as tannins, fiber, and
calcium) which decrease the bioavailability of dietary iron. Iron absorption enhancers include
heme iron sources from animal protein and vitamin C.

Consequences of iron deficiency

 Anemia (low blood haemoglobin concentration)

 Maternal deaths (anemic women are more likely to die from blood loss during delivery- post
partum hemorrhage is a leading cause of maternal death in developing countries)
 Reduced transfer of iron to the foetus, increasing the infant’s risk of iron depletion and anemia
in early infancy
 Low birth weight
 Neonatal mortality
 Reduced physical capacity (the blood needs iron to carry oxygen to the brain and muscles, and
the muscles need iron for normal functioning)
 Reduced productivity
 Reduced learning capacity (anemic children score lower on intellectual tests than non-anemic
children)

Other common non-dietary causes of anemia

 Parasites like hookworms can cause blood loss and increase iron loss.
 Malaria destroys red blood cells and can lead to severe anemia

Iodine: Iodine is a nutrient required for the synthesis of thyroid hormones which are required for the
regulation of cell metabolism throughout life. The thyroid hormones ensure normal growth, especially

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of the brain, which occurs from foetal life to the end of the third year after birth. Promotion of iodized
salt for use by the entire family and encouraging consumption of foods rich in iodine (fish and seafood)
is important.

Causes of iodine deficiency disorders (IDD)

 Iodine-deficient soil resulting in low levels of iodine in locally grown foods and water supply.
 Low dietary iodine intake
 Intake of goiterogenic compounds in the diet (compounds that interfere with the utilisation of
the iodine taken in the diet). These include food with sulphur and thiocyanate compounds such
as cassavas, cabbage
 Selenium deficiency- remember that selenium plays a role in thyroid hormone metabolism

Consequence of iodine deficiency in pre-pregnancy period

 Impaired thyroid function resulting from severe iodine deficiency

 Goiter / enlargement of the thyroid
 Endemic cretinism (extreme form of brain damage and physical impairment)

Calcium: Between 1000 mg to 1200 mg of calcium should be obtained by a woman every day before
conceiving. This may be accomplished by eating three or more servings of calcium rich foods per day
including dairy products and dark leafy vegetables. Like iron, many women fall short on this nutrient.
If there is inadequate calcium in pregnancy, the foetus may draw calcium from the mother's bones,
which can put her at risk for osteoporosis later in life. If a woman is not taking in enough calcium in the
diet, she should take a supplement.

2.6 What to Avoid Before Pregnancy

Vitamin A supplements in large quantities: As much as it is important to take a multi vitamin while
pregnant, mega-vitamin doses in the months preceding conception should be avoided. Doses of
vitamin A in excess of 10,000 IU per day may result in teratogenic effects/ birth defects in the newborn.

Foods: The woman should also avoid all refined carbohydrates, sweets and confectionary which disrupt
blood sugar and hormone balance. Saturated fats and hydrogenated oils found in margarines, butter,
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hard cheese and ice cream which increase inflammation and disrupt hormone production should also be
avoided. Protein which is high in saturated fat such as red meat should be limited. Fish like shark,
swordfish, marlin and tuna are high in the heavy metal mercury and should also be avoided.

Alcohol, cigarettes and caffeine: This should not be taken if one is trying to conceive since
women usually don't know they're pregnant for a few weeks. In addition, caffeine and alcohol
can decrease the ability of a woman to conceive. Caffeine also reduces the body's ability to
absorb iron and calcium.

Stress: Stress can be a factor for reduced fertility. Identify any areas of stress in your life and
change them. Exercise more effective time management, allowing time for relaxation.

2.7 summaries

We have learnt the following about pre-conception nutrition:

 A woman's pre-pregnancy weight is directly related to her baby's birth weight.

 Zinc, selenium, and Vitamins B6 and E boost fertility.
 Adequate stores of iron, folate, iodine and calcium are important before pregnancy
 Folic acid helps reduce the likelihood of recurrent miscarriage, preterm delivery, low birth
weight babies and neural tube defects.
 High vitamin A doses, stress, Alcohol, cigarettes and caffeine should be avoided in the months
preceding conception

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2.9 FURTHER READING

WHO, 1995. Maternal anthropometry and pregnancy outcomes. Bulletin of the World Health
Organization, 73 supplement:1-98.

2.10 Self-test: ii

Now answer the following questions. Each correct answer is worth 1 mark.

1. List three nutritional disorders common in women of reproductive age

2. Explain the reasons for nutrition related pre-pregnancy considerations
3. Give 5 nutrients that boost fertility
4. Give 5 nutrients that favour a healthy pregnancy
5. Outline the consequences of deficiencies in the following nutrients to the mother and child:
 Iron
 Folic acid
 Iodine

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 3.0 NUTRITION DURING PREGNANCY

3.1 INTRODUCTION

Pregnancy is one of the most nutritionally demanding periods in any woman's life. It involves rapid cell
division and organ development. Pregnancy also comes with changes in the body that include a drop in
the levels of electrolytes, proteins, glucose, vitamin B-12, folate, vitamin B-6, and a rise in lipids
triglycerides, and cholesterol in the blood. An adequate supply of nutrients is thus essential to support
both fetal growth and meet maternal needs. All the nourishment the developing baby needs comes from
the mother, through her diet and nutrient supplements. Caloric needs increase by only 15 percent.
However, the requirements for some nutrients double during pregnancy. Pregnant women need to
choose nutrient dense foods to ensure adequate nutritional intake. Diet adjustments help ensure normal
development of the baby and fill the subsequent demands of lactation and breastfeeding. The
consequences of maternal malnourishment include health problems for the mother and an infant of low
birth weight who may have nutritional and other deficiencies.

3.2 LECTURE OBJECTIVES

By the end of this lecture, you should be able to:

 List the nutritional disorders common in pregnancy

 Discuss nutrition related considerations in pregnancy
 Explain the nutrient needs of pregnant women
 Explain the reasons for avoiding intake of specific substances in pregnancy

3.3 Physiological stages in pregnancy

Pregnancy can be divided into 3 stages with nutritional implications:

Implantation- This occurs in the first 2 weeks of pregnancy when the fertilised ovum attaches to the
wall of the uterus. During this stage, the embryo is nourished through uterine milk (secretions of the
outer layers of the fertilised egg)

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Organogenesis- This is the period of the next 6 weeks. Here, the embryo begins to differentiate into
functional units that will later become organs like the heart, lungs, and liver. The skeletal development
also begins at this period. This means that most congenital abnormalities originate from deficiencies
during this period. For instance, a cleft lip is associated with folate, niacin and Vitamin A deficiency.
At this time, nourishment comes from blood and degenerating cells in the space between the embryo
and the walls of the uterus.

Growth- This covers the remaining 7 months of pregnancy. There is rapid increase in number of cells
and cell growth. Nourishment is usually by the placenta. Nutritional deficiency at this time will usually
result in pre-maturity or a smaller infant rather than congenital abnormalities.

3.4 Nutrition disorders in pregnancy

Common nutrition disorders in pregnancy are:

 Vitamin A deficiency
 Iron deficiency
 Iodine deficiency disorders
 Energy deficiency
 Hypertension

Other disorders not common but are significant enough to mention are:

 -Obesity
 -Diabetes

3.5 Nutrition related considerations in pregnancy

Healthy Weight Gain

Many women are usually concerned about weight gain during pregnancy. Some fear gaining too much
weight, wondering if they will get back to their pre-pregnancy size while others feel that they may not
be gaining enough. The weight a woman gains in pregnancy is more than just the weight of the baby.
Approximately 3 to 4 kilos of the total weight is the baby, and the remaining weight consists of an

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increased fluid volume, larger breasts and uterus, amniotic fluid, and placenta. In order to produce a
healthy baby, the body requires extra fluids-extra water, blood, and amniotic fluid. During pregnancy,
the woman gains about 7 to 10 kilograms in water alone.

A total weight gain of about 12 to 15 kilograms is usually recommended, with the pattern of gain
considered more important than the number of kilograms. Weight gain should be at its lowest during
the first trimester, and should steadily increase, with the mother-to-be gaining the most weight in her
third trimester, when the foetus and placenta are growing the most. Inadequate weight gain in
pregnancy increases the risk of delivering a baby of low birth weight. This may cause problems with
the baby's development and growth. Too much weight gain on the other hand, increases the risk of
having a high-birth weight baby and of getting diabetes while pregnant (gestational diabetes). This may
lead to prolonged labour and higher risk of illness for the mother. Women who gain more than the
recommended amount of weight in their pregnancy, should not diet to lose weight. Cutting out food and
calories can put both mother and baby at risk.

How much weight you should gain during pregnancy depends on maternal body weight and height
(Body mass index) before becoming pregnant.

Average weight gain in each area during pregnancy:

 Blood – 2 Kgs
 Extra fluids/fluid retention – 1to 1.5 Kgs
 Energy stored as fat for pregnancy and breastfeeding – 2.5 to 4 Kgs
 Placenta and amniotic fluid - 2 to 3 Kgs
 Baby - 3 to 4 Kgs
 Breasts - 1 to 1.5 Kgs
 Uterus - 1 to 1.5 Kgs

Birth weight

Some infants are low-birth-weight babies, weighing less than 2500 grams. A good number of these are
premature babies, while others are small due to intrauterine growth retardation (IUGR) despite being
full term babies. Under-nutrition is the major cause of IUGR in developing countries. It is attributed to

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small maternal size at conception (low weight and short stature), and low gestational weight gain. Other
important causes include malaria in endemic areas and maternal infections that can cause loss of
appetite, higher nutrient losses or requirements, abnormal placental blood flow or structure, or foetal
infections.

Low birth weight babies have an increased susceptibility to infection, immature kidneys, difficulty
regulating temperatures, and problems with protein and carbohydrate metabolism. Other consequences
include increased risk for stunting, poor neuro-developmental outcomes, work capacity, chronic
disease, and mortality and morbidity. The risks for low birth weight babies are increased among:

 Children born to adolescent mothers since they compete for nutrients as the mother also has
high growth requirements
 Parents of low socio-economic status
 Shorter (stunted) and underweight mothers
 Malnourished mothers
 Conditions like hypertension and viral infections
 Extensive maternal use of drugs, alcohol and smoking

High risk pregnancies

For women in high-risk categories (e.g carrying twins, heavy smokers, and drug abusers), a prenatal
vitamin supplement is recommended, beginning in the second trimester. The supplement should contain
iron, zinc, copper, calcium, and vitamins B6, B9, C and D.

Babies born to adolescent mothers are also usually considered high risk as the mother also has high
nutritional needs for her still growing body.

Preeclampsia

Symptoms of preeclampsia, also known as pregnancy induced hypertension, include swelling (and
proteinuria (excess protein in urine). Preeclampsia risk is associated with first pregnancies, advanced
maternal age, African ethnicity, and women with a past history of diabetes, hypertension, or kidney

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disease. In severe cases, delivery is usually induced.
Sugar

Sugar is an occasional concern in pregnancy. Virtually all women excrete more glucose in their urine
when they are pregnant. Diabetic women however, should be closely monitored to ensure that their
blood sugar values are at or near normal. A high sugar intake by women experiencing excessive weight
gain or having difficulty maintaining normal glucose levels could lead to increased maternal risk for
complications associated with excess weight gain, such as gestational diabetes, hypertension, premature
delivery, and a large for gestational age foetus.

Nausea and Vomiting

In the first few months of pregnancy many women feel sick and nauseated due to changes in hormone
levels. This can impact on the food acceptance and intake of the mother. To help them feel better,
expectant women can eat bread, dry cereal or biscuits before getting out of the bed in the morning,
avoid skipping meals, eat small meals more frequently rather than three large meals, and avoid drinking
fluids with a meal but drinking them before or after. Foods high in fat, fried food, coffee and those with
strong smells or flavours should also be avoided.

Constipation.
Constipation can be due to pressure of the baby against the bowel, hormonal changes and a reduction in
physical activity. High fibre foods and fluids help relieve constipation. The woman should be advised
to drink plenty of fluids and eat more whole grain breads and cereals, vegetable, fruits and legumes
such as beans, peas and lentils. Being physically active is also important.

Heartburns

Heartburns occur due to the pressure of the baby against the mother’s stomach. The following tips may
help in managing heartburn:

 Eating smaller, more frequent meals

 Not lying down for at least one to two hours after eating
 Wearing loose fitting clothing

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  Eating slowly and chewing food well
 Drinking fluids between meals rather than with meals
 Avoiding spicy, fatty foods and coffee

Cravings

During pregnancy some women crave non-food items such as ice, clay, dirt, cigarette ashes, or starch.
This is called pica. When a woman has pica during pregnancy, it may indicate a lack of a specific
vitamin or mineral, making it important to inform their health care provider in case of such cravings or
having eaten non-food items. Non-food items can be dangerous to the mother and baby.

3.6 Specific Nutrient Needs

During pregnancy, the body goes through a lot of hormonal, physiological, and physical changes thus
has increased nutritional needs. Although the old saying "eating for two" isn't entirely correct, more
macronutrients and micronutrients are indeed required during pregnancy. Generally, most women can
meet these increased nutritional needs by choosing a diet that includes a variety of nutritious foods,
including 8 to 10 glasses of water a day, and by taking a nutrient supplement prescribed by their health
care provider. A simple way to ensure that mother and baby are getting all the nutrients needed is by
taking a variety of foods from each of the food groups daily.

Table 3.1 Additional daily requirements for a pregnant woman

Nutrient Additional daily requirements for a pregnant woman

Calories 300- 350gms (in the second and third trimesters)
Protein 60 gms
Calcium 1200 mg
Folate 15 mg
Iron 30 mg

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Essential Fatty Acids: Essential fatty acids (linoleic acid and linolenic acid) are very important for the
baby's normal retinal and brain development. Pregnant women are encouraged to include some sources
of essential fatty acids in their daily eating pattern. Sources of essential fatty acids include: soybean,
non-hydrogenated margarines, oily fish, nuts and seeds.

Calories: It is recommended that pregnant women eat an average of 150 calories more per day in the
first trimester and 350 calories more per day in the two subsequent trimesters than they did before
becoming pregnant. This is so as to ensure adequate weight gain throughout the pregnancy. Calories are
required for normal growth and birth weight, and for fat stores to be used during lactation.

Complex Carbohydrates: A pregnant woman's calories should come from all three energy sources
(Macro-nutrients) - proteins, fats, and complex carbohydrates. A carbohydrate restricted diet during
pregnancy puts the foetus at risk. Without carbohydrates, the body will burn proteins and fat for fuel.
This will lead to:

Protein: Adequate protein is vital since they are the building blocks of all materials in the growing
foetus (brain cells, hair, nails and other tissues). It is also needed for the buildup of the mother’s
muscles, uterus, breasts and blood supply. Low protein intake is related to smaller-than-average weight
babies who may have health problems.

Animal products have all the essential amino acids and are considered complete proteins. Vegetarian
sources lack in one or more of the essential amino acids and are considered incomplete proteins unless
they are combined properly. About 60-80 grams of protein is required daily by pregnant women (6-8
servings).

Table 3.2 Protein servings in grams

Dairy -1 Cup Grams Meat-120gms Grams Beans-1cup Grams Nuts -1cup Grams
Milk 9 Chicken 20 Black Beans 22 Almonds 21
Yogurt 8 Liver 20 Chickpeas 13 Cashews 19
Soy Milk 8 Beef 22 Lentils 16 Peanuts 30
Egg 1 6 Lamb 20 Peas 16 Peanut Butter 1/3cup 13

20
 Veal 23 Soybeans 35 Sesame Seeds 15
Vegetarians should combine a serving form the bean column with complex carbohydrates and nuts or
dairy to have a "complete" protein meal.

Zinc: Inadequate levels during pregnancy can cause prolonged labour and low birth weight babies with
health problems. The dietary intake for zinc should be 11-12 milligrams per day.

Calcium and Vitamin D: Adequate Calcium and vitamin D are important for both mother and baby
during pregnancy. The two nutrients work together to build strong bones and teeth for the baby. They
also help to keep the mother’s bones and teeth strong throughout pregnancy, preventing maternal bone
loss. When the mother’s diet is low in calcium during the pregnancy, the baby will draw off maternal
stores to get the calcium it needs to develop. This can put the mother at increased risk for osteoporosis
and dental problems. A low calcium diet can also lead to insomnia, irritability and leg cramps. About
1200-1500mg of calcium is required daily. Some good sources of calcium and vitamin D include: milk,
yogurt, cheese, broccoli, orange juice with added calcium and fortified soymilk. Kales, almonds, and
fishes eaten with bones like ‘omena’, sardines and salmons are also rich in calcium. It is however
important to remember that phosphorus in sodas, and oxalic acid in spinach, beet greens, and chocolate
decrease the absorption of calcium. Also important to know, is that some vitamin D is made by the skin
from exposure to the sun.

Iron: Pregnant women need more iron than usual because their body is manufacturing more blood -
blood volume increases by 60% in pregnancy. Iron supplies oxygen and nutrients to the foetus,
supports placental function, manufactures red blood cells, and acts as insurance against blood loss
during delivery. Iron from meat is better absorbed than from plants. Iron from plants is absorbed better
if taken with vitamin C or meat protein. Coffee, tea, bran, and calcium decrease absorption.

It is practically not possible to get enough iron from food and so supplements are usually
recommended. The dietary reference intake for iron is 27 milligrams per day for all pregnant women.
Without adequate iron, the foetus will draw its supply from the mother, often leaving her anaemic.
Routine preventive iron supplementation for all pregnant women is recommended. In the third trimester

21
the baby will begin creating its own iron reserve for its first six months of life when it will be primarily
living on milk which is low in iron.

Folate/folic acid: As we saw in the previous lecture, Folate/folic acid helps to decrease the risk of
neural tube defects that affect a baby's spine and brain, such as spina bifida. Folate is the form of the
vitamin found in food and folic acid is the form found in pills. It is especially important for women to
take a multivitamin that contains 0.4mg of folic acid before becoming pregnant and during the first few
months of pregnancy. Although a multivitamin is recommended this does not reduce or replace the
need to make healthy food choices. In the previous lecture, we looked at the consequences of folate
deficiency.

Iodine: As we discussed in the previous lecture, Iodine is required for the synthesis of thyroid
hormones that in turn are required for the regulation of cell metabolism throughout the life cycle. We
said that thyroid hormones ensure normal growth, especially of the brain, which occurs from foetal life
to the end of the third post-natal year.

Consequence of iodine deficiency on intelligence

 Impaired thyroid function resulting from severe iodine deficiency during pregnancy, resulting in
a lower metabolic rate, growth retardation, brain damage, increased perinatal mortality, and
other defects
 Goiter (enlargement of the thyroid),Endemic cretinism, especially in women before and during
pregnancy
 Irreversible mental retardation, resulting from iodine deficiency during pregnancy. Iodine
deficiency is the most prevalent cause of preventable mental retardation in the world.

The following practices can help expectant women get the nutrients needed for a healthy pregnancy:

 Taking a variety of foods from each food group, and limit use of the oils and solid fats.
 Eating regular meals
 Taking breakfast every day

22
  Eat healthy snacks between meals - Follow your appetite. When you are hungry between meals
choose healthy foods such as yogurt, fruit, vegetables, oatmeal muffins, whole grain biscuits,
nuts, etc.
 Taking a prenatal vitamin daily - Remember a prenatal vitamin does not reduce or replace a
healthy diet. It will help you get the extra vitamins and minerals you need while you are
pregnant.
 Eating 7-8 servings of fruits and vegetable each day. Choose colourful vegetables and fruits
whenever you can. These are a great source of folate, vitamins and fibre.
 Eating 6-7 servings of Grain products each day - Choose whole grain breads, cereals, crackers,
pasta and rice. Grain products are a great source of carbohydrate (energy), iron and fibre.
 Eating 2 servings of milk and dairy products each day - are all great sources of calcium and
protein. Non-dairy foods that also contain calcium are salmon with the bones, broccoli, and
almonds.
 Eating 2 servings of meats and other proteins each day - For a great source of iron and protein
choose leaner meat, fish, poultry, eggs, lentils, beans, tofu and peanut butter.
 Taking 30 grams of dietary fibre every day.
 Taking 8 or more glasses of water each day.
 Salt to taste.

3.8 SUMMARY

By now, you should know the following about nutrition in pregnancy:

 Inadequate weight gain in pregnancy increases the risk of a baby of low birth weight
 Too much weight gain increases the risk of having a high-birth weight baby and getting diabetes
while pregnant (gestational diabetes).
 Maternal under-nutrition is the major cause of Intra-uterine growth deficiency.
 Micronutrient deficiencies during pregnancy have consequences for the developing foetus.
Iodine deficiency disorders may cause foetal brain damage or stillbirth. Folate deficiency may
result in neural tube or other birth defects and preterm delivery, and both iron deficiency

23
 anaemia and vitamin A deficiency may have significant implications for the future infant's
morbidity and mortality risk, vision and cognitive development.
 Burning fats due to inadequate carbohydrate, can release ketones that can be destructive to
foetal brain cells and the delicate acid-base balance of the foetal system.
 Large doses of Vitamin A in pregnancy could result in teratogenicity/ birth defects

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3.10 FURTHER READING

Stevens-Simon, Catherine, and McAarney, Elizabeth R. (1992). "Adolescent Pregnancy: Gestational

Weight Gain and Maternal and Infant Outcomes." American Journal of Diseases of
Children 146:1359–1364.

WHO, 1995. Maternal anthropometry and pregnancy outcomes. Bulletin of the World Health
Organization, 73 supplement:1-98.

3.11 SELF-TEST: III

You can now answer each of the following self-test questions.

1. List the nutritional disorders common in pregnancy

2. Discuss the importance of adequate weight gain in pregnancy
3. Outline the nutrient needs of pregnancy
4. Give reasons why the following are not recommended in pregnancy.
o Intake of alcohol
o Cigarette smoking
1. Explain the consequences of low birth weight on the individual.

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 4.0 NUTRITION DURING LACTATION

4.1 INTRODUCTION

During and immediately after the pregnancy, a mother has to make a choice as to the mode of feeding
she will use for her baby. Nutrition education and counseling is thus important to inform the mother on
the recommended and available options. In addition, support from family and other people surrounding
the mother play an important role in feeding choices and maintaining of that choice. Exclusive
breastfeeding is recommended for the first 6 months after birth, and continued breastfeeding thereafter
up to at least 24 months and beyond. We shall discuss more on infant and young child feeding in the
next two lectures. For now, we will concentrate on the milk supply – the mother.

Women’s bodies have an amazing ability to produce a sufficient quantity and quality of breast milk to
support an infant, even if the woman is malnourished. However, breastfeeding women do need an
increased amount of calories and nutrients to maintain their milk supply. A woman who breast-feeds
spends 600 to 800 more calories than one who does not. She also has increased needs for specific
macro and micro-nutrients.

Most of the time, the best way to get an adequate number of calories and nutrients is to eat a healthy,
nutritionally adequate diet that includes vegetables, fruits, protein, whole grains, and a limited amount
of fat, sometimes with a multivitamin supplement. The recommendations for nutrients in lactation are
based on the daily milk production- averaged 750 milliliters. Generally, a mother can produce enough
milk for her infant and two others.

4.2 LECTURE OBJECTIVES

By the end of this lecture, you should be able to:

 Differentiate between breastfeeding and lactation

 Describe the hormonal control of lactation
 Explain the nutrient needs of lactation
 Explain the reasons for avoiding intake of specific substances during lactation

26
4.3 Definition of some related

Colostrum- a thick yellow fluid first secreted by the breast after birth to nourish the born baby. It
contains large amounts of immune factors, proteins, minerals and carotenoids.

Foremilk- milk secreted at the beginning of a breastfeeding session

Hindmilk- milk secreted at the end of a breastfeeding session

Breastfeeding- the act of feeding an infant / child with milk from the human breast

Lactation- Production of milk by the mammary glands

We now know the difference between breastfeeding and lactation- one is an action, while the other is a
physiological process.

4.4 Hormonal control of lactation

During pregnancy, estrogen from the ovary stimulates breast development. Milk flow on the other hand
is initiated after the infant begins to suckle the breast. The vigorous suckling stimulates the anterior and
posterior pituitary glands. The anterior pituitary gland produces the hormone ‘prolactin’ which
stimulates milk production in response to emptying of the breast at a feeding. The posterior pituitary
glands release the hormone ‘oxytocin’ which stimulate the release of milk (let down reflex) from the
breast in response to suckling by the infant. It does this by causing contraction of smooth muscles that
line the alveoli and milk ducts. Emotions have an influence on oxytocin production such that
sometimes when a mother hears her child crying, a let-down may occur. Emotions or pain may also act
in the contrary by inhibiting the let-down reflex. Thus being relaxed is key to optimal breastfeeding.

Another hormone, ‘progesterone’, produced in the placenta also stimulates milk production.

4.5 Milk composition (quality and quantity)

Human breast milk is generally adequately balanced in all the nutrients required by a baby, up to the
age of 6 months. After 6 months, the infant’s needs outstrip the breast milk supply, necessitating
complementary foods. Looking at specific nutrients, maternal malnutrition must be very severe before

27
the total milk fat content is reduced. However, the fatty acid profile reflects maternal dietary intake. In
addition, the fat content varies within a feed. Hind milk which is secreted at the end of a breastfeeding
session contains substantially more fat than foremilk which is secreted at the beginning of a
breastfeeding session. Energy, protein, fat and carbohydrate content is relatively constant. Protein
content tends to decline slightly with duration of lactation but is not affected by maternal under
nutrition.

Nutrients whose low maternal intake or stores reduce their content in breast milk and consequently
impacting on infant development include Vitamins A, B1, B2, B6 and B12, and Iodine and selenium.

Infant stores of most of these nutrients are low and readily depleted, making the infant dependent on a
consistently adequate supply from breast-milk and/or complementary foods. Their concentration in
breast-milk can be rapidly restored by increasing maternal intake.

There is another group of nutrients that maternal intake and stores have little effect on human milk
concentrations and infant status. Because milk concentrations are not reduced when the mother is
deficient, she is vulnerable to further depletion during lactation. They include Vitamin D, folic acid,
calcium, iron, copper and zinc. Supplementing the mother with these nutrients during lactation is likely
to benefit her more than the infant.

4.6 Breastfeeding and lactation Suckling

Breastfeeding is required for the continued synthesis of prolactin and release of oxytocin and it thus
needed for the maintenance of milk production (lactation) and let-down. Adequate milk output in turn
boosts the mother’s confidence and ability to breastfeed without milk shortages. Early supplementation
of breast milk with other foods (before 6 months of age) leads to less vigorous suckling which in turn
results in reduction in milk output. Therefore, the two (breastfeeding and lactation) have an amplifying
effect on each other. Have you ever heard of women complaining of inadequate milk? If so, find out
about their infant feeding practices.

4.7 Contraceptives and lactation

28
The use of oral contraceptives both before conception and during lactation is known to lead to lowered
milk production. In some cases, some nutrient stores are reduced due to the drugs. An example is
Vitamin B6.

4.8 Specific Nutrient Needs

We will now look at maternal nutrient requirements during lactation. Did you to know that the daily
maternal nutrient needs during lactation exceed the needs during pregnancy? Women who are healthy
and eat a well-balanced diet that includes meat and fish do not usually need to take a vitamin
supplement while breastfeeding. However, all women, including those who breastfeed, should ensure
that they consume an adequate amount of calcium and vitamin D.

Calories: The energy and nutritional requirements of women who breastfeed are greater than that of
women who are not. Women who breastfeed exclusively usually need an additional 500-550 calories
per day to maintain their weight. Despite the fact that dietary intake has little impact on the milk
production of a woman, a breastfeeding woman should consume at least 1500 calories per day to avoid
excessive weight loss, which could affect the breast milk output.

Protein: Very low protein intakes results in a reduction in the quantity rather than quality of milk. A
daily intake of 15 grams for the first 6 months followed by 12 grams per day there after is
recommended.

Calcium: Pregnancy and breastfeeding cause a temporary decrease in bone mass which is usually
regained after a woman stops breastfeeding. All adult women should consume a daily minimum of
1000 mg of calcium; adolescents should consume 1300 mg of calcium per day. If it is not possible to
consume enough milk or other foods that contain calcium, it is reasonable to take a calcium
supplement.

Vitamin D: Calcium absorption depends on having an adequate level of vitamin D. Both breastfeeding
and non-breastfeeding women require at least 5 micrograms per day of vitamin D when sunlight is
inadequate; dependent on the season and geographic position. Milk is the best source of dietary vitamin
D, with approximately 2.5 micrograms per cup.

29
Iron: Women who are not anemic after delivery and who breastfeed exclusively do not usually have a
menstrual period for the first four to six months. Thus, there is little iron lost in menstrual blood. An
iron supplement is not usually needed during this time. However, women who are anemic or lost a lot
of blood after delivery usually require an iron supplement.

Folacin: Folacin deficiency is common in pregnancy and thus many women enter lactation with little
reserves. Supplementation may thus be necessary.

Riboflavin: Riboflavin is used in milk production and thus a woman should increase her intake by
0.5mgs.

Vitamin B6: This is especially important for women who are long term users of oral contraceptives,
since their sources are usually depleted.

Vitamin A: An intake of 6000 IU is adequate for the average lactating woman. However, a vitamin A
supplementation of high-dosage (200,000IU) should be given soon after delivery but no later than 8
weeks post-partum to protect lactating women in vitamin A deficiency endemic areas.

Fluid intake: The average woman who exclusively breastfeeds produces about 750 to 800 ml of breast
milk per day. It is adequate for a woman to drink when she is thirsty and to watch for early signs that
she is not getting enough fluids - dark coloured urine, infrequent urination, dry mouth.

4.9 What to avoid during lactation

Fish: Some fish have high levels of methyl mercury, a type of mercury. High levels of mercury in the
blood can be harmful to an infant or child's developing nervous system. Avoid eating any shark,
swordfish, king mackerel, or tilefish, as they have high levels of mercury. Eat no more than two
servings a week of fish and shellfish that are lower in mercury e.g. shrimp, canned light tuna, salmon,
and catfish. Do not eat more than one serving per week of cooked fish that was caught in a local pond,
river, lake, or ocean.

Alcohol: When a breastfeeding woman consumes alcohol, a small amount is passed into her breast
milk. For an average-weight woman, it takes about two hours for one serving of alcohol to clear
completely from her body.
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Caffeine: Most breastfeeding women can drink moderate amounts of caffeine without it affecting their
infant. However, some infants are sensitive to caffeine and become irritable or have difficulty sleeping,
even with small amounts of caffeine. The sensitivity to caffeine usually lessens over time.

Tobacco: Infants of parents who smoke have an increased risk of a number of conditions, including
pneumonia, asthma, ear infections, bronchitis, and sudden infant death syndrome (SIDS), among
others. Reducing or stopping smoking can decrease these risks. However, women who smoke are still
encouraged to breastfeed their children.

Illegal drugs: Such as marijuana, amphetamines, phencyclidine (PCP), cocaine and heroin are not safe
for both mother and baby. Women who use these drugs should not breastfeed.

4.10 SUMMARY

 Infant suckling stimulates milk flow, the hormone ‘prolactin’ stimulates milk production and
‘oxytocin’ stimulates the release of milk (let down reflex) from the breast in response to suckling by
the infant.
 Maternal malnutrition must be very severe before the total milk fat content is reduced.
 The fatty acid profile of breast milk reflects maternal dietary intake. In addition, the fat content
varies within a feed.
 Hind milk contains substantially more fat than foremilk
 Energy, protein, fat and carbohydrate content of breast milk is relatively constant.
 Nutrients whose low maternal intake or stores reduce their content in breast milk and consequently
impacting on infant development include Vitamins A, B1, B2, B6 and B12, and Iodine and
selenium.
 Maternal intake and stores have little effect on human milk concentrations and infant status for
Vitamin D, folic acid, calcium, iron, copper and zinc. Supplementing the mother with these
nutrients during lactation is likely to benefit her more than the infant.
 When a lactating woman consumes alcohol, some amount is passed into breast milk.
 Infants of parents who smoke have an increased risk of pneumonia, asthma, ear infections,
bronchitis, and sudden infant death syndrome (SIDS), among others.

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4.12 FURTHER READING

Wilde, C.J. et al,. Breastfeeding: matching supply with demand in human lactation. Proceedings of the
Nutrition Society, 54: 401–406 (1995).

4.13 SELF-TEST: IV

To check how well you have mastered this lecture, answer the following questions. Each question is
worth 1 mark.

Differentiate between the following:

 Breastfeeding and lactation

 Hind milk and fore milk

Describe the hormonal control of lactation

Explain the nutrient needs of lactation

Explain the reasons for avoiding intake of the following substances during lactation:

 Certain fish
 Tobacco

Supplementing the mother with Vitamin D, folic acid, calcium, iron, copper and zinc during lactation is
likely to benefit her more than the infant. Explain

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 5.0 NUTRITION IN INFANCY AND

EARLY CHILDHOOD (CHILDREN AGED 0-59 MONTHS)

5.1 INTRODUCTION(factors making them vulnerable)

Children aged less than five years are usually vulnerable to malnutrition and childhood illnesses. About
11 million children aged below five years die every year worldwide of causes that are preventable and
treatable, the main causes being pneumonia, diarrhoea, malaria, measles and malnutrition. The period
from birth to 24 months is particularly a critical window for the promotion of optimal growth, health,
and behavioural development. It is also the peak age for growth faltering, micronutrient deficiencies,
and common childhood illnesses. In the first year, there is very rapid growth with the infant's birth
weight tripling by the first birthday and length increasing by half. Infants who do not receive sufficient
calories, vitamins, and minerals usually do not reach their expected growth levels. The gains in weight
and height are the primary indices of nutritional status and their accurate measure at regular intervals
are compared with standard growth charts (growth monitoring).

Chronic under nutrition during this period causes irreversible damage to the malnourished individual
and the society in general. It not only leads to a substantial increase in under-five mortality and the
overall global disease burden, but also causes productivity losses in adulthood, leading to lower
cognitive and physical abilities. This affects the individual’s income earning potential for life, making it
difficult to rise out of poverty. Moreover, malnourished children who put on weight rapidly later in
childhood and adolescence are more prone to chronic diseases like diabetes, hypertension and
cardiovascular diseases. Globally, more than half of child deaths (3.5 million annually) are associated
with under nutrition.

5.2 LECTURE OBJECTIVES

By the end of this lecture, you should be able to:

- List the nutritional disorders common in children aged 0-59 months

- Explain the recommended breastfeeding practices

33
 - Discuss ways of optimizing breastfeeding
- Describe the appropriate complementary feeding for infants and young children
- Outlinethe nutrient needs of children aged 0-59 months

5.3 NUTRITIONAL DISORDERS IN 0-59 MONTHS

Currently, the most common nutritional disorders in children under five years in developing countries,
Kenya included, are:

 Protein-energy malnutrition
 Vitamin A deficiency
 Iron deficiency
 Iodine deficiency disorders

In addition, there are disorders that are prevalent in specific populations and are emerging or re-
emerging in other populations due to environmental changes, emergency situations and changing food
and lifestyle habits.

 Rickets – Calcium and/ or Vitamin D deficiency

 Beriberi – thiamine deficiency
 Pellagra- Niacin deficiency
 Scurvy
 Zinc deficiency
 Dental fluorosis
 Obesity

5.4 INFANT AND YOUNG CHILD FEEDING (0-24 MONTHS)

The age range from conception (-9 months) to 23 months is known as the ‘window of opportunity’
because preventing under nutrition during this period of life benefits children throughout their lifetime.
It is estimated that breastfeeding can prevent up to 13% of all child deaths, and reduce diarrhoeal
mortality by 24–27% among infants aged 0–5 months. Exclusive breastfeeding and continued

34
breastfeeding up to 23 months of age also enhances linear growth and substantially reduces the burden
of infection in children. Appropriate complementary feeding on the other hand could eliminate 6% of
all under-5 deaths. Optimal IYCF practices are thus critical to optimal child growth, development,
health and survival.

The World Health Organization and UNICEF recommend exclusive breast-feeding for the first six
months of life and the continuation of breast-feeding, together with appropriate complementary
feeding, up to two years of age or beyond. Exclusive breastfeeding is giving an infant no other food or
drink (not even water), apart from breast milk (including expressed breast milk), except for vitamins,
mineral supplements or medicines in the form of syrups or drops. A summary of the continuum of
infant and young child feeding is shown in figure 5.1. While breast-feeding is highly encouraged, iron-
fortified infant formula is also acceptable for infants, if breast-feeding is not possible.

5.4.1 BREASTFEEDING

5.4.1.1 Nutritional benefits for the infant

Human breast-milk is superior to all substitutes, including commercial infant formula and is the best
food for babies. This is because it provides all the nutrients needed for the first 6 months (26 weeks) of
life, serving the unique needs of the human infant. By now you know that the composition of human
milk is not constant. It changes during feeds, according to the time of day, and during the course of
lactation. The total volume of maternal milk production and infant milk intake is also variable. The
mean milk intake by infants is often put at 650–850 ml per day, but it may range from very little to
more than 1 litre per day. This is dependent on the frequency and effectiveness of suckling.

Fat

Breast-milk has an energy density of about 67 calories /100 ml. Fat represents around 50% of its total
energy content. The foremilk is more watery and higher in lactose and a relatively low fat
concentration, which rises so that the most energy-dense milk is secreted at the end of the feed. The
hind milk therefore makes a vital contribution to the infant’s energy intake. The fat-rich milk flows
more slowly but provides important energy and nutrients, so feeds should not be ended when the flow
of milk slows or the infant’s suckling becomes less vigorous. Compared to cow’s milk, human milk has

35
a higher percentage of unsaturated fatty acids and a higher concentration of essential fatty acids. In
addition, the long-chain polyunsaturated fatty acids (LCPUFAs) in breast-milk are better absorbed than
those in cow milk which are important for normal neurodevelopment and visual cortical function.
Newborns’ capacity to convert essential fatty acids to LCPUFAs is limited in the first few months and
they rely on the efficient transfer of LCPUFAs from the mother, prenatally via the placenta and
postnatally from breastmilk. Milk fats are also the vehicle for the uptake of the fat-soluble vitamins.

Carbohydrates

The main carbohydrate in human milk is lactose, which accounts for about 40% of its total energy, and
is efficiently digested and absorbed in the small intestine. The unabsorbed lactose passes to the large
bowel where it is fermented by colonic bacteria to short-chain fatty acids and lactate. These are
absorbed and make a contribution to energy intake and reduce the pH of the colon, enhancing calcium
absorption. In addition, lactose promotes the growth of lactobacilli and may help to develop a
favourable colonic flora that protects against gastroenteritis. In acute gastrointestinal infection, formula-
fed infants at times become lactose-intolerant due to epithelial damage and loss of lactase activity. This
can be addressed by changing to a lactose-free formula. Human milk also contains significant
concentrations of oligosaccharides which play a function in the defence against viruses and bacteria or
their toxins. The oligosaccharides also promote the growth of the colonic flora, including strains with
possible probiotic effects such as bifidobacteria.

Protein

The protein content of breast-milk is appropriate for the nutritional needs of infants despite being less
than a third of that of cow’s milk. Human milk is whey-predominant with all the essential amino acids,
whereas cow’s milk is casein-predominant. The major whey protein found in cow’s milk (and thereby
in infant formula), is β- lactoglobulin, which is absent in human milk and can result in an antigenic
reaction when fed to infants. The casein in human milk has chemical properties that make it easier for
the human infant to digest than the casein found in the milk of other mammals. A proportion of milk
protein, particularly in colostrum, is in the form of the immunoprotective proteins immunoglobin A,
lactoferrin, lysozyme and other macromolecules which protect the infant from microbiological
infections.
36
Vitamins and minerals

From the previous chapter on nutrition in lactation, you now know that women of marginal nutritional
status can produce milk of adequate quantity and quality for normal infant growth. However, optimal
micronutrient quality of human milk and consequently optimal micronutrient status of the infant
depends on the mother having good nutritional status. The mother’s dietary intake mostly affects the
concentration of the water-soluble vitamins and, to a lesser extent, the fat-soluble vitamins. However,
with few exceptions, neither maternal intake nor maternal stores affect the amount of minerals secreted
in breast-milk. There is also usually a plateau above which a further increase in intake will have no
effect in increasing their concentrations in milk. As long as the mother’s micronutrient status is
satisfactory during pregnancy and lactation, exclusively breastfed infants less than 6 months of age do
not need a vitamin or mineral supplementation. Where there are micronutrient deficiencies however,
dietary improvement or supplementation of the mother is likely to be effective, and will benefit both
mother and baby.

Vitamin A

Vitamin A plays a role in growth and in the development and differentiation of tissues, particularly the
epithelia of the gastrointestinal and respiratory tracts. Human milk, especially colostrum, is a good
source of the vitamin. Breastfed infants rarely show signs of deficiency even at low intakes, but may
have subclinical deficiency if maternal vitamin A status is poor.

Vitamin D

Vitamin D is obtained through the skin by the action of ultraviolet radiation. The vitamin D status of
the newborn depends on the vitamin D status of the mother during both pregnancy and lactation. If it is
poor, infant stores will be low and vitamin D levels in the breast-milk will be inadequate unless the
infant receives sufficient exposure to ultraviolet light or is supplemented.

Folate

Breast-milk has a high folate concentration, which is maintained at the expense of maternal stores.
Breast-milk folate concentrations do not fall unless the mother is severely depleted.

37
Iron

Human milk has relatively low concentration of iron that is highly bio-available. There is little risk of
iron deficiency anaemia before 9 months of age in infants of normal birth weight who are breastfed
exclusively for at least 4 months and who continue to be breastfed on demand. Iron concentrations in
human milk are not correlated with maternal iron status and are relatively unaffected by the iron
content of the maternal diet. Breastfeeding helps to prevent anaemia in infants and anaemic mothers
should go ahead and breastfeed.

Zinc

Like iron, the concentration of zinc in breast-milk is relatively low, but it is highly bio-available and is
much better absorbed than zinc in commercial infant formula or cow’s milk. Zinc deficiency is rare in
exclusively breastfed infants before 6 months of age. During the first 6 months of lactation, the zinc
concentration in human milk is unaffected by variations in dietary zinc intake (including supplements)
or maternal zinc status in well nourished women. Consumption of non-breast-milk foods by an infant
can significantly reduce the bioavailability of zinc and iron in breast-milk.

5.4.1.2 Non-nutritional benefits for the infant

Apart from fostering enhanced bonding between mother and baby, breast feeding has other benefits.
Human milk contains immunological and bioactive substances, absent from commercial infant
formulas, which protect from bacterial and viral infections and may aid gut adaptation and development
of the newborn. Colostrum also contains antibodies, anti-infection agents, anti-inflammatory factors,
growth factors, enzymes and hormones that foster growth and development.

Breastfeeding protects infants from infection by two mechanisms:

 It reduces exposure to bacterial pathogens transmitted by contaminated food and utensils.

 It contains antimicrobial factors and other substances that strengthen the immature immune
system and protect the digestive system of the newborn infant, thus protecting against
infections, especially those of the gastrointestinal and respiratory tracts. Colostrum is especially

38
 rich in antibodies, anti-infection agents, anti-inflammatory factors, growth factors, enzymes and
hormones.

The principal immune-proteins in human milk are secretory immunoglobulin A which acts on mucosal
surfaces to protect them from injury by ingested microbial antigens, and lactoferrin which is an iron-
binding protein that competes with bacteria for iron, thus reducing bacterial viability and thereby the
risk of enteric infections.

There is proof that breastfeeding is beneficial to the infant’s health. Apart from reducing the risk for
eczema, colic and other allergies, it has been found to protect against childhood illnesses like diarrhoeal
diseases, respiratory infections, and otitis media. Auto-immune diseases such as diabetes mellitus type I
and inflammatory bowel disease are also less in breast fed infants. Breast fed infants are usually less
likely to die from sudden infant death syndrome or develop adiposity and obesity later in childhood. In
terms of infant development, breast milk is associated with higher IQ scores, jaw shape and
development, and improved visual acuity and psychomotor development.

5.4.1.3 Benefits for the mother

 It enhances bonding between mother and infant

 Early initiation of breastfeeding after delivery promotes maternal recovery from childbirth by
accelerating uterine contraction thus reduces the risk of post-partum haemorrhage. This reduces
maternal mortality and preserves maternal haemoglobin stores.
 It prolongs postpartum an ovulation / infertility, thus child spacing
 It helps in weight loss and return to pre-pregnancy body weight.
 It reduces risk of pre-menopausal breast cancer and ovarian cancer.
 It is thought to improve bone mineralization thus reducing the risk of postmenopausal hip
fractures
 It is convenient and readily available since no special preparations or equipment is needed
 It is more economical than other feeding alternatives

5.4.1.4 MANAGEMENT OF BREASTFEEDING

We will now look at the practical aspects of successful breastfeeding. The following are vital:
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  Immediately after birth, a healthy baby instinctively searches for food, and ideally breastfeeding
should begin within the first hour. Mothers should be encouraged and helped to have skin-to-
skin contact with their babies and should be accommodated together.
 Colostrum should not be discarded or withheld from infants in favour of prelacteal feeds.
 Good positioning of the baby’s body and good attachment at the breast is important. Health
workers should help and teach mothers on correct position and attachment to the breast.
 Breastfeeding should be on demand since it establishes and maintains optimum lactation.
 The baby should drain the first breast before the second is offered to ensure that he or she
receives optimal quantities of the energy-rich hind milk.
 Practices that interfere with the infant’s desire or ability to breastfeed effectively, such as the
provision of supplementary fluids (water, glucose, sugar water, teas, herbal drinks, juices, milks
and other fluids) are not necessary. They displace the richer, more nutrient-dense breast-milk,
and interfere with infant suckling thus compromising breastfeeding.
 Anxiety may have a negative impact on milk secretion, and mothers thus need active and
ongoing support to breastfeed well into the second year or beyond. Family, friends, the
community and health workers should provide this support. Thus programs targeting them
should be put in place.
 Poor weight gain raises the possibility that the infant is not receiving enough milk from the
mother. However, this may be an indication to improve counseling and breastfeeding support
rather than to start using alternatives to breast-milk.

Remember that breast-milk output is programmed to meet the demands of the infant, and that
breastfeeding frequency and milk output are positively correlated. Infants should suckle regularly and
the intensity and duration of breastfeeding should be maintained. When infant demand increases, the
mother should respond by breastfeeding more often and longer at each feed.

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5.4.1.5 BREAST FEEDING SUBSTITUTES

Cows’ milk

Infants should not be given unmodified cow’s milk as a drink before the age of 9 months. If infants are
fed formula, cow’s milk can be gradually introduced into their diet between the ages of 9 and 12
months. If there are no economic constraints, however, it may be better to continue with formula until
12 months of age.

Cow’s milk differs greatly from human breast milk in terms of the quality and quantity of nutrients and
immunological factors. Whole cow’s milk has greater amounts of protein and minerals (calcium,
sodium, phosphorus, chloride, magnesium and potassium) and less carbohydrate, essential fatty acids
(linoleic and α-linolenic acids) and long-chain polyunsaturated fatty acids, iron, zinc, vitamin C and
niacin. The quality of cow milk protein differs from human milk and is potentially allergenic to the
human infant. Whole cow milk may cause low Vitamin C intake since the vitamin is usually easily lost
when a food is heated. Cow milk may also predispose an infant to anaemia because it contains little
iron and in addition, its allergens may cause stomach bleeding. The high protein and sodium intake may
also impose a high renal load on the baby’s less developed kidneys.

Some parents give skimmed and semi-skimmed milk to infants. Since skimmed milk has had most of
the fat removed and semi-skimmed milk about half of the fat removed, they do not provide enough
energy for the growing infant. Sweetened condensed milk is also not recommended because of its high
sugar content.

Fruit juices, sugar-water and dilute cereal gruels or porridges are sometimes given instead of milk
feeds, but these are not recommended as alternatives in the age bracket of 0-6 months because of their
nutritional incompleteness.

Bottle feeding

Bottles and artificial teats are one method of feeding infants when they cannot be fed directly from the
breast. Cup feeding, however, is becoming increasingly preferred and is particularly recommended in
areas where hygiene is poor, and for feeding infants under special conditions.

41
Both bottles and artificial teats can be harmful because:

 They increase the risk of diarrhoea (where hygiene is poor), dental disease and otitis media, and
may change oral dynamics
 Chances that the infant will receive inadequate stimulation and attention during feeds are high
 Bottles and teats need to be thoroughly cleaned and sterilized and this takes time and fuel, and if
not well done, infection is probable
 Bottles may cause “nipple confusion” in the infant, which may interfere with breastfeeding.

An alternative method of feeding infants who cannot breastfeed is using a cup, especially when the
infant is expected to breastfeed later and where hygienic care of bottles and teats is difficult.

Advantages of cup feeding

 The baby uses his or her tongue while feeding thus develops eating skills
 They are easier to clean than bottles
 Cups are less likely than bottles to be carried around for a long time, thus reducing the
opportunity for bacteria to multiply
 Cup feeding requires the mother or other caregiver to hold and have more contact with the
infant, thus providing more psychosocial stimulation
 Cup feeding is better than feeding with a cup and spoon, because spoon feeding takes longer
and the mother or caregiver may stop before the infant has had enough.

5.4.1.6 GLOBAL INITIATIVES ON PROMOTING BREAST FEEDING

Each country is expected to support, protect and promote breastfeeding by achieving the four targets
outlined in the Innocenti Declaration:

 Appointment of an appropriate national breastfeeding coordinator

 Universal practice of the Baby Friendly Hospital Initiative
 Implementation of the International Code of Marketing of Breast-milk Substitutes and
subsequent relevant resolutions of the World Health Assembly

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  Legislation to protect the breastfeeding rights of working women.

THE BABY FRIENDLY HOSPITAL INITIATIVE

To ensure successful establishment and maintenance of breastfeeding at population level, policies and
programmes that promote breastfeeding are necessary. In 1992, UNICEF and WHO launched the Baby
Friendly Hospital Initiative worldwide. They summarize the maternity practices necessary to establish a
supportive environment for women wishing to breastfeed and thereby to bring about improvements in
the incidence and duration of breastfeeding. To become a baby friendly hospital, every facility that
contributes to maternity services and to the care of newborn infants must implement the following 10
steps:Ten steps to successful breastfeeding

 Have a written breastfeeding policy that is routinely communicated to all health care staff.
 Train all health care staff in skills necessary to implement this policy.
 Inform all pregnant women about the benefits and management of breastfeeding.
 Help mothers initiate breastfeeding within a half hour of birth.
 Show mothers how to breastfeed, and how to maintain lactation even if they should be separated
from their infants.
 Give newborn infants no food and drink other than breast-milk, unless medically indicated.
 Practice rooming-in – allow mothers and infants to remain together 24 hours a day.
 Encourage breastfeeding on demand.

Apart from developing public health policies on child nutrition, governments are urged to implement
the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health
Assembly resolutions. In 1981, the International Code of Marketing of Breast-milk Substitutes was
adopted by the World Health Assembly as a “minimum requirement” to be enacted “in its entirety” in
“all countries”. Since then, resolutions have been adopted by the World Health Assembly, further
clarifying and strengthening the Code. These resolutions require that:

 Follow-on milks are not necessary and complementary foods should not be promoted too early
 Obstacles to breastfeeding should be removed from health services, workplace and community

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  Complementary feeding practices should be fostered from about 6 months of age, emphasizing
continued breastfeeding and local foods
 There should be no free or subsidized supplies of breast-milk substitutes in any part of the
health care system
 Governments should ensure that financial support for professionals working in infant and young
child health does not create conflicts of interest
 Governments should ensure truly independent monitoring of the Code and subsequent relevant
resolutions
 The marketing of complementary foods should not undermine exclusive and sustained
breastfeeding.

These resolutions have the same status as the Code itself and should be read together with it.

5.4.1.7 Summary of World Health Assembly resolutions on the International Code of Marketing of
Breast-milk Substitutes

1. No advertising of any breast-milk substitutes (any product marketed or represented to replace breast-
milk) or feeding bottles or teats.

2. No free samples or free or low-cost supplies to mothers.

3. No promotion of products in or through health care facilities.

4. No contact between marketing personnel and mothers (mother craft nurses or nutritionists paid by
companies to advise or teach).

5. No gifts or personal samples to health workers or their families.

6. Product labels should be in an appropriate language and no words or pictures idealizing artificial
feeding (pictures of infants or health claims) should be used.

7. Only scientific and factual information to be given to health workers.

8. Governments should ensure that objective and consistent information is provided on infant and
young child feeding.

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9. All information on artificial infant feeding, including labels, should clearly explain the benefits of
breastfeeding and warn of the costs and hazards associated with artificial feeding.

10. Unsuitable products, such as sweetened condensed milk, should not be promoted for babies.

11. All products should be of a high quality and take account of the climatic and storage conditions of
the country in which they are to be used.

12. Manufacturers and distributors should comply with the Code [and all the resolutions] independently
of any government action to implement it.

5.4.2 COMPLEMENTARY FEEDING

Complementary feeding is the provision of foods or fluids to infants in addition to breast-milk.

Complementary foods can be classified as:

Transitional foods- these are complementary foods specifically designed to meet the particular
nutritional and physiological needs of the infant

Family foods- these are complementary foods given to the young child that are broadly the same as
those consumed by the rest of the family. Children are physically capable of consuming family foods
by 1 year of age, after which they no longer need to be modified to meet the special needs of the infant.

The age for weaning (introducing transitional foods) is a particularly sensitive time in infant
development since it’s a period of rapid growth. Sub-optimum feeding practices during this critical
period may increase the risk of growth faltering (wasting and stunting) and nutritional deficiencies and
may have long-term effects on health and mental development. Thus, nutritional interventions and
improved feeding practices targeted at infants are among the most cost-effective that health
professionals can promote.

Appropriate complementary feeding is:

Timely – foods are introduced when the need for energy and nutrients exceeds what can be provided
through exclusive and frequent breastfeeding (6 months)

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Adequate – foods provide sufficient energy, protein, and micronutrients to meet a growing child’s
nutritional needs

Safe – foods are hygienically stored and prepared, and fed with clean hands using clean utensils and not
bottles and teats

Properly fed – foods are given consistent with a child’s signals of appetite and satiety, and that meal
frequency and feeding method are appropriate. Actively encourage the child to consume sufficient food
using fingers, spoon or self-feeding as per age.

Timely introduction of appropriate complementary foods promotes good health, nutritional status and
growth of infants and young children. Complementary foods should be introduced at about 6 months of
age with breast-milk continuing to be the main type of milk consumed by the infant. This is around the
age when their digestive system is mature enough to digest a range of foods.

5.4.2.1 Disadvantages of early introduction of complementary feeding

 Complementary foods can displace breast-milk, leading to reduced production of breast-milk

and thus the risk of insufficient energy and nutrient intake
 The infant is exposed to potentially contaminated foods thus increasing the risk of diarrhoeal
disease and consequently malnutrition
 The risks of diarrhoeal disease and food allergies are increased because of intestinal
immaturity, increasing the risk of malnutrition
 Mothers become fertile earlier, because decreased suckling reduces the period during which
ovulation is suppressed.

5.4.2.2 Disadvantages of late introduction of complementary feeding

 Inadequate provision of energy and nutrients from breast-milk alone may lead to growth deficits
and malnutrition
 Micronutrient deficiencies, especially of iron and zinc, may develop as breast-milk is unable to
meet increased requirements

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  The optimal development of motor skills such as chewing, and the infant’s acceptance of new
tastes and textures, may be delayed.

It is therefore necessary to introduce complementary foods at the appropriate developmental stages.

5.4.2.3 Signs that an infant is ready for complementary feeding

 Teeth begin to erupt

 They are able to sit without support
 The infant shows interest in what others are eating
 Salivates when others are eating
 Physiologically, the kidneys mature, gastric acidity increases and digestive enzymes are
produced.

5.4.2.4 COMPOSITION OF COMPLEMENTARY FOODS

As infants grow, the consistency of complementary foods should change from semi-solid to solid foods
(Beikost) and the variety of foods offered should increase. By eight months, infants can eat ‘finger
foods’ and by 12 months, most children can eat the same types of food as the rest of the family. To feed
a young child successfully, families must ensure that feeding frequency is adequate and must give high
quality foods preferentially to the child.

Dietary diversity

Children 6–23 months of age should take foods from 4 or more food groups from the following 7 foods
groups:

 Grains, roots and tubers

 Legumes and nuts
 Dairy products (milk, yogurt, cheese)
 Flesh foods (meat, fish, poultry and liver/organ meats)
 Eggs
 Vitamin-A rich fruits and vegetables

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Other fruits and vegetables

Consumption of foods from at least 4 food groups ensures the child has a high likelihood of consuming
at least one animal-source food and at least one fruit or vegetable that day, in addition to a staple food
(grain, root or tuber).

Meal frequency

Children 6–23 months of age should be fed solid, semi-solid, or soft foods (including milk feeds for
non breastfed children) the minimum number of times or more.

 2-3 meals per day for infants aged 6-8 months;

 3-4 meals per day for infants aged 9-11 months and children 12-24 months
 Additional nutritious snacks may be offered 1-2 times a day, as desired.

Energy density and viscosity

The main factors influencing the extent to which an infant can meet his or her energy and nutrient
requirements are the consistency and energydensity (energy per unit volume) of the complementary
food and the frequency of feeding. Starches often provide the principal source of energy, but when
heated with water starch granules gelatinize to produce a bulky, thick (viscous) porridge. These
physical properties make the porridge difficult for infants to both ingest and digest. Furthermore, the
low energy and nutrient density means that large volumes of food have to be consumed to meet the
infant’s requirements. Dilution of thick porridges to make them easier to swallow will further reduce
their energy density. The addition of some oil can make staples softer and easier to eat even when
cold. Starch-containing foods can also be improved by mixing with other foods, although it is
essential to be aware of the effects of such additions, not only on the viscosity of the food but also on
its protein and micronutrient density. For example, while the addition of animal fats, oil or margarine
increases the energy content, it has a negative effect on protein and micronutrient density. Therefore,
starch-containing foods should be enriched with foods that enhance their energy, protein and
micronutrient contents. This can be achieved by adding milk (breast-milk, commercial infant formula
or small amounts of cow’s milk or fermented milk products), which improves protein quality and
increases the density of essential nutrients.

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Nutrient density and bioavailability

In general, the bioavailability of minerals from plant products is poor compared with that from animal
products. Micronutrients that have poor bioavailability when consumed in plant products include iron,
zinc, calcium and β-carotene in leafy and some other vegetables. In addition, the absorption of β-
carotene, vitamin A and other fat-soluble vitamins is impaired when diets are low in fat.

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Fruit juices

Fruit juices are those produced by compressing fruits. They are a good source of vitamin C, and if
given as part of a meal will improve the bioavailability of non-haem iron present in plant foods. It is
nevertheless important to limit the volume given to avoid interfering with the intake of breast-milk and
with the diversification of the diet. Furthermore, fruit juices contain sugars, and because of their acidity
can cause dental caries and erosion of the teeth.

Tea

Tea is a popular drink in Kenya but is not recommended for infants and young children because it
contains tannins and other compounds which bind iron and other minerals, thereby reducing their
bioavailability. Furthermore, sugar is often added, which increases the risk of dental caries. Also, sugar
consumed in tea may blunt the appetite and inhibit the consumption of more nutrient-dense foods.

5.4.2.5 GUIDING PRINCIPLES FOR COMPLEMENTARY FEEDING THE BREASRFEEDING CHILD

1. Duration of exclusive breastfeeding and age of Introduction of complementary foods: Practice

exclusivebreastfeeding from birth to six months of age, and introduce complementary foods at
six months of age while continuing to breastfeed.

2. Maintenance of breastfeeding: continue frequent, on-demand breastfeeding until two years of age
or beyond.

3. Responsive feeding: practice responsive feeding, applying the principles of psycho-social care.
Specifically:

 Feed infants directly and assist older children when they feed themselves, being sensitive to
their hunger and satiety cues
 Feed slowly and patiently, and encourage children to eat, but do not force them
 If children refuse many foods, experiment with different food combinations, tastes, textures and
methods of encouragement
 Minimize distractions during meals if the child loses interest easily

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  Remember that feeding times are periods of learning and love − talk to children during feeding,
with eye to eye contact.

4. Safe preparation and storage of complementary foods:

Practice good hygiene and proper food handling by:

 Washing caregivers’ and children’s hands before food preparation and eating
 Storing foods safely and serving foods immediately after preparation
 Using clean utensils to prepare and serve food
 Using clean cups and bowls when feeding children
 Avoiding the use of feeding bottles, which are difficult to keep clean.

5. Amount of complementary food needed: start at six months of age with small amounts of food and
increase the quantity as the child gets older, while maintaining frequent breastfeeding. The energy
needs from complementary foods for infants with “average” breast milk intake in developing countries
are approximately 200 cal per day at 6−8 months of age, 300 cal per day at 9−11 months of age, and
550 kcal per day at 12−23 months of age.

6. Food consistency: gradually increase food consistency and variety as the infant gets older, adapting
to the infant’s requirements and abilities. Infants can eat pureed, mashed and semi-solid foods
beginning at six months. By eight months most infants can also eat “finger foods” (snacks that can be
eaten by children alone). By 12 months, most children can eat the same types of foods as consumed by
the rest of the family (keeping in mind the need for nutrient-dense foods, as explained in 8 below).
Avoid foods that may cause choking (i.e., items that have a shape and/or consistency that may cause
them to become lodged in the trachea, such as nuts, grapes, raw carrots).

7. Meal frequency and energy density: increase the number of times the child is fed as he/she gets
older. The appropriate number of feedings depends on the energy density of the local foods and the
usual amounts consumed at each feeding. For the average healthy breastfed infant, meals of
complementary foods should be provided 2−3 times per day at 6−8 months of age and 3−4 times per

51
day at 9−11 and 12−24 months of age. Additional nutritious snacks (such as a piece of fruit or bread or
chapatti with nut paste) may be offered 1-2 times per day, as desired. Snacks are defined as foods eaten
between meals, usually self-fed, convenient and easy to prepare. If energy density or amount of food
per meal is low, or the child is no longer breastfed, more frequent meals may be required.

8. Nutrient content of complementary foods: feed a variety of foods to ensure that nutrient needs are
met. Meat, poultry, fish or eggs should be eaten daily, or as often as possible. Vegetarian diets cannot
meet nutrient needs at this age unless nutrient supplements or fortified products are used (see 9 below).
Vitamin A-rich fruits and vegetables should be eaten daily. Provide diets with adequate fat content.
Avoid giving drinks with low nutrient value, such as tea, coffee and sugary drinks such as soda. Limit
the amount of juice offered so as to avoid displacing more nutrient-rich foods.

9. Use of vitamin-mineral supplements or fortified products for infant and mother: use fortified
complementary foods or vitamin-mineral supplements for the infant, as needed. In some populations,
breastfeeding mothers may also need vitamin-mineral supplements or fortified products, both for their
own health and to ensure normal concentrations of certain nutrients (particularly vitamins) in their
breast milk. Such products may also be beneficial for pre-pregnant and pregnant women.

10. Feeding during and after illness: increase fluid intake during illness, including more frequent
breastfeeding, and encourage the child to eat soft, varied, appetizing, favourite foods. After illness, give
food more often than usual and encourage the child to eat more.

5.4.3 Specific WHO nutrient intake recommendations for 0-6years

The following tables show the recommended nutrient intake as recommended by the World Health
Organization for children aged 0months to 6years.

Table 5.1 Energy and protein requirements by World Health Organization

AGE ENERGY PROTEIN

In calories per day In grams per day
Boys Girls

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 0-3 months 545 515 12.5
4-6 months 690 645 12.7
7-9 months 825 765 13.7
10-12 months 920 865 14.9
1-3 years 1230 1165 14.5
4-6 years 1715 1545 19.7

Table 5.2 Vitamin requirements by World Health Organization

AGE Vitamin A Vitamin D Vitamin E Vitamin C

RE/ day µg/day mg/kg body weight mg/day
0-3 months 350 10 0.15-2 20
4-6 months 350 10 0.15-2 20
7-9 months 350 10 0.15-2 20
10-12 months 350 10 0.15-2 20
1-3 years 400 10 0.15-2 20
4-6 years 400 10 0.15-2 20

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Table 5.3 B complex Vitamins requirements by World Health Organisation

AGE Vitamin B1 Vitamin B2 Vitamin B3 Vitamin B9 Vitamin B12

mg/ day mg/day mg/day µg /day µg/day
0-3 months 0.3 0.5 5.4 16 0.1
4-6 months 0.3 0.5 5.4 24 0.1
7-9 months 0.3 0.5 5.4 32 0.1
10-12 months 0.3 0.5 5.4 32 0.1
1-3 years 0.5 0.8 9.0 50 0.5
4-6 years 0.7 1.1 12.1 50 0.8
Table 5.4 Mineral requirements by World Health Organization

It AGE Iodine Zinc Calcium Copper Selenium Iron is

µg/ day mg/ day mg/day mg/day µg /day mg/day

0-3 months 40 5.3 500 0.33-0.55 6 -
4-6 months 40 3.1 500 0.37-0.62 9 -
7-9 months 50 5.6 600 0.6 12 8.5
10-12 months 50 5.6 600 0.6 12 8.5
1-3 years 70-120 5.5 400 0.56 20 5.0
4-6 years 70-120 6.5 450 0.57 24 5.5
important to note the following in line with these recommendations:

 Iron bioavailability is inhibited by phytates, oxalates and polyphenols in plant foods. Thus to
maximise on plant sources, Vitamin C rich foods should be taken along plant foods. Iron from
animal sources is heme-iron and are readily absorbed.
 Calcium bioavailability is also inhibited by phytates, oxalates and polyphenols in plant foods.
The famous composite flours for making complementary foods like porridge are believed to

54
 have these anti-nutrients and thus the calcium in them is non-bioavailable. This predisposes the
children who rely on these flours as their main food to rickets. Fermentation and germination is
believed to counteract this effect.
 Children aged 5 years and below are prone to childhood illnesses and thus need nutrients that
boost their bodies’ defences. Vitamin A, Zinc, selenium and iron are important for this
immunity
 Very high fibre diets are not recommended for young children. Their systems are not developed
enough to maximize absorption. High amounts interfere in the absorption of iron and other
micronutrients by binding them, decreasing intestinal transit time and making them physically
unreachable due to bulk.
 Children need fat and moderate sugar for energy for their growing bodies.

Importance of Maternal Nutrition

As you have learnt from both the previous and current chapter, women of poor nutritional status can
produce milk of both adequate quantity and quality to support normal infant growth. You have also
learnt that in such cases, maternal nutrient stores will be depleted. You should however note that this
can be detrimental if the intervals between pregnancies are short and there is insufficient time for the
mother to replenish her nutrient stores. Moreover, the fat content of breast-milk may be compromised if
maternal fat stores are low. To ensure an optimal quality and quantity of breast-milk without
compromising the health of the mother, it is thus important to optimize maternal nutritional status
throughout pregnancy and lactation.

Vitamin A supplementation

In Kenya and other countries where Vitamin A deficiency is a risk, preventative supplementation is
usually done for children aged 6 months–5 years old every 6 months. Mothers should be sensitised on
the importance of bringing their children for these supplementations. In addition, for all sick children
with measles, severe malnutrition, and prolonged or severe diarrhoea, high-dose vitamin A supplements
are recommended.

Immunization

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Taking the children for the full course of immunization before their first birthday is an important
element in the nutritional and health status, since immunization is a preventive measure against many
diseases. Vaccine-preventable diseases account for approximately 10% of the global burden of diseases
in children less than five years of age and correspond to nearly 3 million child deaths per year. Measles
accounts for most vaccine preventable deaths. Additionally, providing vitamin A supplements as part of
measles case management can reduce the case fatality rate by more than 50%. A full course of
compulsory immunization in Kenya today includes Measles, Hepatitis B, Heamophilus influenza,
Poliomyelitis, Tuberculosis, Pneumonia, MMR (Measles, Mumps, Rubella) and DPT (Diphtheria,
Whooping cough, Tetanus). Optional ones include Yellow fever, Rotavirus, Chicken pox, Hepatitis A,
Meningitis, Typhoid andCholera.

Growth monitoring and promotion

Growth promotion is motivating caretakers, families, communities, and health workers to practice
behaviours that support adequate growth (height and weight gain) in young children. These behaviours
include adequate preconception and prenatal nutrition for mothers to build a strong foundation for
infant growth; breastfeeding and complementary feeding; and preventive health care, such as
immunizations and deworming; micronutrient supplementation; timely and appropriate attention to
illnesses; and others. Growth monitoring is measuring the weights and/or heights of individual children
periodically (e.g., monthly) to see if they are growing adequately. It can help detect underlying medical
problems before they become serious and can reinforce good caring practices. Health workers should
pay special attention to the counselling and follow-up components of growth monitoring activities in
their area. Growth monitoring/promotion efforts should focus on young children from birth to 2 years
and should ideally begin with monitoring nutrition practices in pregnant women.

Importance of appropriate child care

The main elements of childcare are child feeding, hygiene and sanitation, child health seeking
behaviour and child stimulation. Broken down, they are immunisation, breast feeding, complimentary
feeding, micronutrient supplementation, hygiene, use of treated bed nets, home treatment, health care
seeking, adherence to health advice, and child stimulation. These elements of childcare have a direct
56
impact on child health, growth and development. Even when poverty results in a lack of food and
limited health care, enhanced care giving can optimize the use of existing resources to promote healthy
normal development.

Food, health and care must all be satisfactory so as to enjoy good nutrition status. Breastfeeding
provides all of these simultaneously.

SUMMARY

In summary, we have learnt that:

 The age range from conception (-9 months) to 23 months is known as the ‘window of
opportunity’ because preventing under nutrition at this time benefits children throughout their
lifetime.
 The World Health Organization and UNICEF recommend exclusive breast-feeding for the first
six months of life and the continuation of breast-feeding, together with appropriate
complementary feeding, up to two years of age or beyond.
 Human breast-milk is superior to all substitutes and is the best food for babies.
 Colostrum has the proteins immunoglobin A, lactoferrin, lysozyme and other macromolecules
which protect the infant from microbiological infections.
 Breastfeeding enhances bonding between mother and infant, promotes maternal recovery from
childbirth by accelerating uterine contraction thus reduces the risk of post-partum haemorrhage
and prolongs postpartum anovulation / infertility.
 Breast-milk output is programmed to meet the demands of the infant, thus breastfeeding
frequency and milk output are positively correlated.
 Appropriate complementary feeding is: Timely, adequate in energy, protein, and micronutrients,
safe, and properly fed – foods are given consistent with a child’s signals of appetite and satiety,
and that meal frequency and feeding method are appropriate.
 Consumption of foods from at least 4 food groups ensures the child has a high likelihood of
consuming at least one animal-source food and at least one fruit or vegetable that day, in
addition to a staple food (grain, root or tuber).
 Infants should not be given unmodified cow’s milk before the age of 9 months.
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5.7 FURTHER READING

Richter SB, et al. (2006). Normal infant and childhood development. In JA McMillan et al., eds., Oski's
Pediatrics: Principles and Practice, 4th ed., chap. 96, pp. 593–601. Philadelphia: Lippincott Williams
and Wilkins.

Evidence for the ten steps to successful breastfeeding. Geneva, World Health Organization, 1998
(document WHO/CHD/98.9). 74.

International Code of Marketing of Breast-milk Substitutes. Geneva, World Health Organization, 1981.

SELF-TEST: V

Find out how well you have understood this lecture by answering each of the following questions. List
the nutritional disorders common in children aged 0-59 months

Define the following:

 Exclusive breast feeding

 Complementary feeding
 Transitional complementary foods
 Colostrum

Describe the appropriate complementary feeding for infants and young children

Explain the disadvantages of early introduction of complementary foods

Explain the nutritional superiority of breast milk to other infant foods

58
 6.0 NUTRITION IN CHILDHOOD AND ADOLESCENCE

6.1 INTRODUCTION

Most children will grow about two inches and gain about 2 to 4 kilos per year. School age children
(ages of 6 and 12 years), will grow an average of one to two feet and almost double in weight.
Diminished weight-for-height (BMI) may indicate acute under-nutrition, while decreased height-for-
age may suggest chronic under-nutrition. Such growth deficits may be due to malnutrition,
psychosocial deprivation, eating disorders, underlying chronic disease, infection, or other factors.

After 4 years of age, a child's energy requirements per kilogram of bodyweight are decreasing but the
actual amount of energy (calories) required increases as the child gets older. From 5 years to
adolescence, there is a period of slow but steady growth. Dietary intakes of some children may be less
than recommended for iron, calcium, vitamins A and D and vitamin C. In most cases deficiencies are
unlikely as long as the energy and protein intakes are adequate and a variety of foods, including fruit
and vegetables, are eaten. Regular meals and healthy snacks that include carbohydrate-rich foods, fruits
and vegetables, dairy products, lean meats, fish, poultry, eggs, legumes and nuts should contribute to
proper growth and development without supplying excessive energy to the diet.

Children should also drink plenty of fluids, especially if it is hot or if they are physically active. Water
and other sources of fluid such as milk and milk drinks, fruit juices and soft drinks can provide needed
fluids.

6.2 LECTURE OBJECTIVES

By the end of this lecture, you should be able to:

 List the nutritional disorders common in adolescence

 Discuss nutritional concern in childhood and adolescence
 Explain the nutrient needs in childhood and adolescence

6.3 CHILDHOOD

6.3.1 Nutritional concerns in childhood

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Meal Patterns

To meet energy needs, children should eat at least three meals a day, beginning with breakfast. Eating
breakfast affects both cognitive and physical performance; that is, if a child eats breakfast, he or she
may be more alert in school and better able to learn and to perform sports or other physical activities.
Snacks also form an integral part of meal patterns for children. Young children often cannot eat large
quantities of food at one sitting and often feel hungry before the next regular mealtime. Parents can
pack healthy mid-morning and mid afternoon snacks to be taken by the child at school.

School lunches

One of the meals that parents may not have control over is school lunches. The school thus has the
responsibility to ensure that the school lunch is healthy and wholesome. Parents can in addition
provide nutrient dense snacks to be taken before and after lunch, and provide nutritious breakfasts and
supper to bridge for the gap that may exist. In cases where parents are responsible for their children’s
lunch, parents should pack healthy but simple and convenient to eat foods. Possibilities include meaty
sandwiches and pies, roast chicken pieces with potatoes, and fruits and vegetables like cucumber,
broccoli, and peas, among others. Including water and a drink like a fruit juice, fruity yoghurt or milk is
also recommended.

Food preferences

Children often have food likes and dislikes. However, parents should make available a wide variety of
foods and encourage the tasting of new foods in small quantities. In addition, parents are advised not to
force children to “clean their plates.” Children may benefit from choosing their own portion size,
provided that the food is wholesome and nutritious. Food should also not be used to reward or punish
behaviour.

Dental health

Nutrients essential for good dental development are fluorine, calcium, phosphorus and vitamins A, D
and C. The development of tooth decay however, is more dependent on the nature of the dietary
carbohydrate as this is one of the essential conditions for tooth decay. The stickier the carbohydrate and

60
the longer it is in the mouth, the greater the cariogenic effect. Fluoride has the greatest protective effect
while sucrose is the major detrimental factor. Children should thus be educated and encouraged to
practice good oral hygiene, apart from a diet rich in the teeth forming nutrients.

Bone development

The achievement of peak bone mass and density during childhood and adolescence is important in
reducing the risk of osteoporosis later in life. Eating several servings of dairy products can help meet
the recommended calcium intake. Apart from calcium, vitamin D and phosphorous, physical activity,
especially weight bearing exercises that stimulate bone building and retention are recommended.

Overweight and Obesity in children

Childhood obesity and overweight are on the rise. When children are overweight, it is recommended
that you aim at reducing the rate of weight gain while allowing for growth and development.
Overweight children and adolescents are more likely to be overweight or obese as adults. Thus, healthy
eating and physical activity are important as a life-long approach to weight management and to overall
good health and quality of life.

Physical Activity for Children

Benefits of regular physical activity include strong bones, good muscle tone, psychological well-being
and reduced risk of developing chronic diseases. In contrast, the long-term consequences of physical
inactivity include an increased risk of type II diabetes, high blood pressure, arthritis, and premature
death. Participation in physical activity tends to decline as children grow older. To maintain good
nutrition and health status, children and adolescents should engage in at least 60 minutes of physical
activity on most, if not all, days of the week.

6.3.2 Specific Nutrient Needs

Calories: Calories are important to provide the needed energy for growth, physical activities and
mental work at school. Boys generally need more calories than girls. To meet these needs, children
should consume food from the three energy sources- proteins, fats, and complex carbohydrates. Care
should be taken not to have too many calories as obesity is a real concern at this age.

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Protein: Protein is important for growth and maintenance of all tissues. Most children easily meet this
requirement with their intake of meat, chicken, eggs, and dairy products which have all the essential
amino acids. Protein is also available from plant sources, including tofu and other soy foods, beans, and
nuts.

Calcium, Vitamin D and Phosphorus: Adequate intake of these nutrients is essential for development
of strong and dense bones, and strong teeth. Calcium is important in the achievement of peak bone
mass and density, which begins in childhood. Good sources include milk, yogurt, cheese, calcium-
fortified juices and cereals.

Essential Fatty Acids: Essential fatty acids (linoleic acid and linolenic acid) are very important for the
child’s normal immunity, and joint and brain health. Sources of essential fatty acids include: soybean,
non-hydrogenated margarines, oily fish, nuts and seeds. Preparations in form of syrups and tablets are
commercially available and can be quite useful.

Iron: Iron is important for blood formation, transport of oxygen and carbon dioxide and immunity. In
childhood, it is especially needed for synthesis of new tissues and production of haemoglobin as blood
volume increases. Children with low iron levels are often found with impaired intellectual function.
This emphasises the importance of adequate iron in the diet of school age children. Also important is to
provide bio-available iron.

Iodine: Iodine is required for the synthesis of thyroid hormones that in turn are required for the
regulation of cell metabolism throughout the life cycle. Thyroid hormones regulate growth and
development and are required for the metabolism of energy. Worth mentioning is that iodine deficiency
can induce brain damage and irreversible mental retardation. School age children benefit from optimal
energy metabolism and factors that promote growth and development- iodine is one such factor.

6.4 ADOLESCENCE

Adolescence is a period from of transition from childhood to adulthood, in which physical, chemical,
and emotional development is accelerated. Adolescents have special nutritional needs due to rapid
growth (fat mass, lean body mass and bone mineralization) and maturational changes associated with
the onset of puberty. Adolescents’ caloric needs vary depending on their growth rate, degree of physical
62
maturation, body composition, and activity level. However, they do need extra nutrients to support the
growth spurt, which, for girls, begins at ages 10 or 11, reaches its peak at age 12, and is completed by
about age 15. In boys, it begins at 12 or 13 years of age, peaks at age 14, and ends by about age 19.
Under-nutrition however, can delay the onset of puberty.

6.4.1 Growth and development in adolescence

The hormonal changes in puberty result in changes in the body composition (fat, muscle, bone) and
skeletal and sexual maturation. There is rapid physical, emotional and biochemical development during
this period. The growth spurt lasts about 2-3 years and begins with weight (there is increase in fat
stores), then height. Between 18-20 years, the adolescents acquire their adult stature. The linear growth
spurt is then followed by accrual of bone mass. This continues until early adulthood. Several years after
growth in height is complete, the pelvic bones are still growing. This is a process that is crucial for
reducing the risk of obstructed labour. The development of the birth canal is not fully completed until
about 2-3 years after growth on height has ceased.

Menarche (time of first menstrual period) in the girls occurs after the period of weight gain. Better
nourished girls have higher pre-menarcheal growth velocities and reach menarche earlier than
undernourished girls. The undernourished grow slower and for longer, because menarche is delayed.
The delay in menarche is thought to be partly related to low iron stores in childhood. In the boys,
sexual development occurs at the same time as the growth spurt. Hormonal changes lead to sexual
maturity and enlargement of organs and tissues like development of breasts and hips in girls, and
muscle and broadening of shoulders in boys. These come with physiological changes that influence
absorption and utilisation of nutrients. However, growth varies widely between adolescence and
consequently nutrient needs. It is thus advisable to relate nutritional needs to secondary sexual
characteristics rather than age.

6.4.2 Nutrition disorders in adolescents

Common nutrition disorders in adolescence are:

 Vitamin A deficiency
 Iron deficiency
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Other disorders not common but are significant enough to mention are:

 Obesity
 Eating disorders
 Chronic energy malnutrition

6.4.3 Nutritional concerns in adolescence

Eating Patterns

Adolescents have a tendency to eat differently than they did as children. They tend to eat away from
home, develop irregular eating habits and skip meals. One of the most frequently missed meals is
breakfast, yet breakfast plays an important role in providing energy and nutrients after an overnight
fast, and helps in concentration and performance at school. To meet their nutritional requirements,
adolescents should eat at least three meals a day, including breakfast. Apart from skipping meals, they
are exposed to periodic food fads and slimming trends. In addition, because of after-school activities
and active social lives, sitting down for three meals a day is not easy and snacks could easily replace
meals. Most snacks are high in fat, salt and sugar and tend to have little nutritional value thus exposing
them to weight gain, diabetes and cardiovascular diseases. Educating the teenager to choose snacks that
are low in fat, salt and added sugar is thus important.

Eating Disorders

Adolescents are a group that is usually at risk for eating disorders since their food choices are often
influenced by social pressure to achieve cultural ideals of thinness, gain peer acceptance, or assert
independence from parental authority. Fear of gaining weight may lead to overly restrictive diets,
exercises, and/or excessive eating as a way of coping with the physical and emotional changes that
come with this age. Some teens resort to self-induced vomiting or laxative use to control their weight.
Girls and women are more prone to eating disorders than boys and men. These disorders predispose an
individual to a heart attack, stroke, anaemia, high blood pressure and high cholesterol, kidney disease
and/or failure, osteoarthritis and bone deterioration.

Overweight and Obesity in adolescents

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Due to lack of physical activity and an increase in the amount of "junk food" available to them, the
prevalence of obesity and overweight among adolescents is on the rise. There is a positive energy
balance (more energy is consumed than is spent). This has led to an increase in obesity-related diseases
like diabetes and heart disease. Overweight children and adolescents are more likely to be overweight
or obese as adults. Therefore, health professionals should emphasize healthy eating and the importance
of staying active to this group.

Peer pressure

Teenagers are particularly vulnerable to peer-pressure, and can easily give in to food and slimming
trends in order to ‘fit in’ with their age mates. Skipping meals, dieting and consumption of or avoidance
of certain foods is likely. It is thus important for parents to make healthy eating part of the socialisation
of their children starting from childhood through adolescence.

Use of oral contraceptives

The use of oral contraceptives is common among girls to avoid pregnancies. They usually have
negative nutritional effects for instance; they reduce serum folate levels which in turn reduce zinc
levels. This then lowers immunity, sexual development and skeletal and muscle growth and
development. Long use of contraceptives also reduces pyridoxine levels in breast milk in the future. On
the flip side, they improve iron levels due to reduced menstrual flow, increase serum copper levels,
calcium absorption and conversion of carotene to vitamin A.

Alcohol, tobacco and recreational drugs

Alcohol impacts negatively on food intake and affects the absorption of nutrients like zinc and folacin.
Hard drugs like cocaine are known to reduce appetite leading to weight loss. Marijuana is said to
increase hunger but its users are known to weigh less than non-users. Smokeless tobacco is known to
increase blood pressure, blood sugar and chances of oral cancer. It also reduces potassium levels in the
body, and intake of fruits and vegetables. Interventions should be developed to provide positive
guidance so that adolescents do not engage in intake of these substances.

Pregnancy in adolescence

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When an adolescent becomes pregnant, she needs enough nutrients to support both her baby and her
own continued growth and physical development. If her nutritional needs are not met, her baby may be
born with low birth weight or other health problems. There is also an increased risk for medical
complications and maternal mortality. For the best outcome, pregnant teenagers need to seek pre-natal
care and nutrition advice early in their pregnancy. Parental guidance is required to avoid early
pregnancies since they have far more implications than just nutrition.

Athletics and sports

Adolescents involved in athletics and other sports may feel pressure to be at a particular weight or
perform at a certain level, and be tempted to adopt unhealthy coping habits like crash dieting, taking
performance boosting supplements, or eating unhealthy foods to fulfil their hearty appetites. For female
athletes taking such measures, there is an increased risk for delayed menarche, irregular menses and
loss of bone density. A balanced nutrient intake is important for a good health status and performance.

6.4.4 Specific Nutrient Needs in adolescents

The nutrient requirements of individual teenagers differ greatly, and food intake can vary enormously
from day to day, so that those with deficient or excessive intakes on one day may well compensate on
the next. In this period of life, several nutrients are at greater deficiency risk including calories, iron,
zinc and calcium. Generally, nutrient requirements are greater for males than females.

Iron: Adolescents are particularly susceptible to iron deficiency anaemia because of their increased
blood volume and muscle mass as they grow and develop. This raises the need for iron for building up
haemoglobin stores in blood and myoglobin in muscle. The increase in lean body mass (LBM),
composed mainly of muscle, is more important in adolescent boys than in girls. In preadolescent years,
LBM is about the same for both sexes. Once adolescence starts, however, the boys undergo a more
rapid accumulation of LBM for each additional kilogram of body weight gained. Menstruation in girls
contributes to elevated iron. Remember that iron from animal foods (haem iron) is much better
absorbed than iron from plant sources (non-haem iron). Vitamin C and animal proteins assists in the
absorption of non-haem iron. A deficiency of iron causes anaemia, which leads to fatigue, confusion,
and weakness. Adolescent boys need 12 milligrams of iron each day, while girls need 15 milligrams.

66
Calcium and Vitamin D: About 45% of adult skeletal mass is formed during adolescence, although its
growth continues past the adolescent period. The achievement of peak bone mass and density during
childhood and adolescence plays an important role in reducing the risk of osteoporosis later in life.
Girls should be keener on these nutrients as they are more at risk for osteoporosis than boys later in life.
The skeleton accounts for at least 99% of the body stores of calcium and the gain in skeletal weight.
Calcium for the growth of the skeleton must be derived from the diet. By eating several servings of
dairy products, green leafy vegetables, calcium-fortified soy products, and other calcium-fortified foods
and beverages, the recommended calcium intake can be achieved. Remember that apart from calcium,
vitamin D and phosphorous are also needed for building of strong bones. Physical activity, especially
weight bearing exercises, is also essential since they stimulate bone building and retention.

Calories: Adolescents need additional calories to provide energy for their rapid growth and activity.
Boys ages 11 to 18 need between 2,500 and 2,800 calories each day. Adolescent girls need
approximately 2,200 calories each day. This is a significant increase from childhood requirements. To
meet these calorie needs, teens should choose a variety of healthy foods, such as whole grains, lean
protein sources, low-fat dairy products, fruits, and vegetables.

Stress and emotional upsets can affect the energy balance in adolescents by making them consume too
little or too much food. Infections, nervousness, menstrual, dental or skin problems (acne) can result in
depression of appetite, and those adolescents on marginal diets are the most vulnerable. We should also
remember that obesity is a potential risk. Simple sugars and saturated fats intake should be controlled.
Including food and nutrition in the school curricula should enable children and adolescents to have the
knowledge to make informed choices about their nutrition.

Protein: Protein is important for growth and maintenance of tissues and muscle. Adolescents need
between 45 and 60 grams of protein each day. In adolescence growth occurs in the breasts, hips,
muscles, blood and most tissues. Remember boys are more muscular as we saw in iron above. Protein
is a limiting factor for growth and should not replace carbohydrate as a main source of energy. It should
account for 12-14 % of the energy intake in adolescence.

Thiamine, Riboflavin and Niacin: These nutrients play a major role in energy metabolism and thus
with the increased energy intake in adolescence, their intake should also be increased.
67
Folate and Vitamin B12: These are essential for DNA and RNA synthesis and are needed in higher
amounts when tissue synthesis is occurring rapidly. Rapid growth in adolescence thus necessitates their
increased need.

Zinc: Zinc is needed for growth and sexual maturation or puberty. Lack of adequate zinc usually results
in hypogonadism and growth retardation in both males and females. Zinc is naturally present in various
foods such as meat, poultry, dairy products, beans, whole grains and nuts are rich in zinc.

6.5 SUMMARY

Here is a recap on what we have discussed in this lecture:

 Eating breakfast affects both cognitive and physical performance- a child who eats breakfast is
more alert in school and better able to learn and to perform sports or other physical activities.
 Children should be educated and encouraged to practice good oral hygiene, apart from a diet
rich in the teeth forming nutrients.
 The achievement of peak bone mass and density during childhood and adolescence is important
in reducing the risk of osteoporosis later in life.
 Overweight children and adolescents are more likely to be overweight or obese as adults.
 Benefits of regular physical activity are strong bones, good muscle tone, psychological well-
being and reduced risk of developing chronic diseases.
 Adolescents are usually at risk for eating disorders since their food choices are often influenced
by social pressure to achieve cultural ideals of thinness, gain peer acceptance, or assert
independence from parental authority.
 A pregnant adolescent needs enough nutrients to support both her baby and her own continued
growth and physical development.
 Iron, protein, folate, calcium, calories and the B vitamins are important in adolescence

68
6.7 FURTHER READING

World Health Organisation and UNICEF, A healthy start in life – Global consultation on child and
adolescent health and development. Stockholm: WHO.

World Health Organization (WHO) (2000). Technical report series 894: Obesity: Preventing and
managing the global epidemic. Geneva: World Health Organization.

6.8 SELF-TEST: VI

 Explain the importance of the following in childhood:

 Breakfast
 Physical activity
 Good bone development
 Explain the nutrient needs in childhood
 List the nutritional disorders common in adolescence
 Discuss the risks associated with the following in adolescence
 Pregnancy
 Oral contraceptives
 Recreational drugs
 Compare the nutrient needs in adolescent boys with those of girls

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 7.0 NUTRITION IN ADULTHOOD

7.1 INTRODUCTION

Adult hood is generally divided in to three stages: early adulthood, middle adulthood and late
adulthood/ elderly. In this module, we will look at late adulthood as a lecture on its own – nutrition in
the elderly. In this lecture, we will cover early and middle adulthood.

7.2 LECTURE OBJECTIVES

By the end of this lecture, you should be able to:

 Describe the early and middle stages of adulthood

 Explain the nutrient needs of adults
 Outline the energy distribution requirements in adults
 Explain the lifestyle changes required for a healthy body in middle adulthood

7.3 Early adulthood

This covers the age range between 20-40yrs. It is the period when one is at their peak of physical
health, fitness (on average at about age 30) and cognitive abilities. In the 20’s, one may still gain
height, muscle and fat, and the brain is still increasing in size and weight (although no new neurons are
being formed). There is increased weight gain from ages 20-50 years- body fat doubles for males, 50%
increase for females. One’s senses are optimal, biological function and physical performance reach
their peak from 20-35 years of age, waning after 35. Strength peaks around 25 years of age, plateaus
through 35 - 40 years of age, and then declines. Flexibility also decreases with age throughout
adulthood. However, there are large individual differences and a fit 40-year-old may out-do a sedentary
20-year-old.

During this stage, the body continues to undergo significant hormonal changes. Men’s beards grow a
little thicker and their voices become slightly deeper and richer. Women reach their peak fertility in
their early 20s. They also gain a little weight and finish their full breast development. Basal metabolism
declines in both sexes compared to puberty.

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Substance abuse occurs, especially in adults who are college students- there is heavy drinking and
addiction is possible. Identity and intimacy are both sought at this stage and marriage and career
choices are made. Men are more likely to die at this age than women, particularly in the 18-25 bracket
due in part to risk-taking behaviour. Regarding disease, cancer is much less common in young than in
older adults. Exceptions are testicular cancer, cervical cancer, and Hodgkin's lymphoma. In sub-
Saharan Africa, HIV and AIDS have hit the early adult population.

7.4 Middle adulthood

This is the second stage of adulthood, from approximately ages 40-60 yrs. There is a decline in physical
skills and strength and flexibility in both genders wane. Vision, light sensitivity, hearing, kidney
function and cardiac output also decrease. Men usually gain weight in the abdominal region, while
women gain weight in the hips and thighs. Women also experience hormonal changes during this
period that result in the loss of the ability to reproduce, a process called menopause. After 55, there is
decrease in height or increase in weight, approximately 2 inches lost for men and 1 inch for women.
Important to note is the decreasing bone density (for women, loss is twice as fast).

This stage also comes with increasing responsibilities, increasing self-(dis)satisfaction and increasing
awareness of time (past, future). The recognition that more than half of one's life is gone may prompt
some to make sudden, drastic changes in order to achieve their goals, while others focus on finding
satisfaction with the present course of their lives. Health wise, this group has fewer accidents but more
chronic diseases, heart disease being most common, then cancer. There is the “catching up” effect of
lifestyle where one used to get away with many unhealthy habits but no longer can. One now requires
active attempt to improve and should create an exercise routine to avoid weight gain. They should also
stop smoking, cut down on alcohol and schedule regular medical tests (blood sugar, mammography,
prostate screening).

7.5 Recommended nutrient intakes in adult hood

Energy: For the adults to perform at their places of work, college, and other responsibilities like
parenting, adequate energy is required. The caloric needs are usually calculated based on body weight,
basal metabolism, physical activity levels and sex. Men generally require more calories than women

71
and so does a person engaged in heavy physical activity (e.g ‘kazi ya mjengo’) compared to one
engaged in light office work. Generally, an energy balance should be achieved (energy in = energy
out). A positive energy balance means excess calories and thus the risk of excessive weight gain. A
negative energy balance on the other hand means that the body is spending more than it is consuming
and could result into under-nutrition.

In middle adulthood when there is the “catching up” effect of lifestyle, one now requires to watch their
energy balance and avoid weight gain. Since women are also in their reproductive age in early
adulthood and part of middle adulthood, they also need to ensure that their body weight is optimal and
favours good birth weight and lactation. The energy sources are also an important aspect; with
carbohydrates the favoured source for most of the calories, followed by fats, then protein. The table
below outlines the recommendations based on the distribution of the sources of energy.

Table 7.1 Energy recommendations for adults

NUTRIENT RECOMMENDATIONS
Protein Minimum of 10% of total energy intake
Maximum of 40% of total energy intake when BMI is less than
25,
Total fat
Maximum of 35% of total energy intake when overweight
Cholesterol Maximum 300 mg/day, intake is not compulsory
Saturated fatty
Maximum 10% of total energy intake, intake is not compulsory
acid
Carbohydrates Minimum of 40% of total energy intake
Dietary Fibre 15-22g/100calories of 28-40g/day

Vitamins: Vitamin levels for adults are also summarised in the table below. Women are generally
vulnerable to deficiencies of Vitamin A, folic acid and Vitamin B12. These are especially important for
women of reproductive age as these vitamin deficiencies impact on pregnancy outcomes. Thiamine,

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Riboflavin and Niacin play a major role in energy metabolism and thus, depending on one’s energy
needs (weight and physical activity level), their intake should also be considered. Vitamin D is another
nutrient worth mentioning as it is involved in calcium absorption and consequently bone mass and
strength. Women are particularly vulnerable to osteoporosis in later years and still have a chance in
early adulthood to maximise their peak bone mass through nutrition and physical activity. Finally, free
radicals play a role in accelerating the process of ageing and cancers. Vitamins A, C and E being
antioxidants, play an important role in reducing free radicals in the body.

Table 7.2 Reference intakes for Vitamins in adults

VITAMIN REFERENCE INTAKES

Vitamin E 0.4 mg α- tocopherol equivalents/ g PUFA
Vitamin C 30-80 mg/day
Vitamin B1 0.5 mg/1000MJ
Vitamin B2 1.2-1.5 mg/day
Vitamin B3 1.6 mg niacin equivalents /MJ
Vitamin B6 15-16 µg/g protein
Pantothenic acid 3-7 mg/day
Biotin 10-200 µg/day
Vitamin A 6.7 µg retinol equivalents /kg body weight
Vitamin D 10 µg/day
Vitamin K 65-80 µg/day
Folic acid 3 µg/kg body weight
Vitamin B 12 1.4-2.0 µg/day
Minerals: The role of minerals cannot be under-estimated in adulthood. Calcium and phosphorus are
essential for achievement of peak bone mass and density, which continues into early adulthood. As you
now know, women as more affected by osteoporosis in old age than men. Iron is also important for
women of reproductive age for the health and survival of both the woman herself and her babies. The
same goes for folic acid and iodine. Zinc and selenium both play a role in fertility, immunity and

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scavenging of free radicals. As we said earlier, free radicals accelerate the process of ageing and
cancers. Thus for adults, these nutrients are important. The table below summarises the
recommendations.

Table 7.3 Recommended amounts of minerals in adults

MINERAL DAILY INTAKE

Sodium 115-200 mg
Potassium 1600-2000 mg
Chloride 750 mg
Calcium 800-1200 mg
Phosphorus 800-1200 mg
Magnesium 330-480 mg
Iron 10 mg
Zinc 2.5 mg
Copper 1-2 mg
Manganese 2-5 mg
Fluorine 1.5-4 mg
Chromium 100 µg
Selenium 50-70 µg
Iodine 150-200 µg
Cobalt As Vitamin B12

7.6 Foods to Avoid

Carbohydrates- Avoid refined and processed carbohydrates, sweets and confectionary which disrupt
blood sugar levels and increase weight gain.

Fats- Saturated fats and hydrogenated oils should be avoided and red meat kept to a minimum.

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Proteins- Limit protein that is high in saturated fat such as fatty red meat and cheese. Avoid fish that
are high in the heavy metal, mercury like shark, swordfish, marlin and tuna.

Fluids- Avoid alcohol, caffeine, high sugar soft drinks, undiluted fruit juices and carbonated drinks.

Processed foods- Avoid processed meats, vegetables, convenience and fast foods as they have
additives, preservatives, food colour, and are high in sugar, salt and fats. These predispose one to non-
communicable diseases like diabetes and cardio-vascular diseases.

Generally, staying physically active and maintaining a diet of fruits, vegetables, whole grains, lean
meats, and dairy products regularly should provide you with the recommended dietary allowance of
vitamins and minerals for a healthy life from early to late adulthood.

7.7 SUMMARY

We have learnt the following in this chapter:

 Adult hood is divided in to three stages- early adulthood, middle adulthood and late adulthood/
elderly.
 In middle adulthood, there is the “catching up” effect of lifestyle and one now requires active
attempt to improve their health status.
 In middle adulthood, it is recommended to schedule regular medical tests (blood sugar,
mammography, prostate screening).
 Men generally require more calories than women and so does a person engaged in heavy
physical activity compared to one engaged in light or moderate activity
 Women are generally vulnerable to deficiencies of Vitamin A, folic acid and Vitamin B12.
 Women are particularly vulnerable to osteoporosis in later years and still have a chance in early
adulthood to maximise their peak bone mass through nutrition and physical activity.
 Calcium and phosphorus are essential for achievement of peak bone mass and density.

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  Finally, free radicals play a role in accelerating the process of ageing and cancers. Vitamins A,
C and E and Zinc and selenium both play a role in fertility, immunity and scavenging of free
radicals.
 Free radicals accelerate the process of ageing and cancers.
 Refined and processed carbohydrates, saturated fats and hydrogenated oils and protein that are
high in saturated fat such as fatty red meat should be avoided.

7.8 ACTIVITIES

Take a 24-hour recall of your diet yesterday. Modify that diet to suit:

i. An adult woman working as an administrative clerk

ii. An adult man working as a labourer at a construction site

7.9 FURTHER READING

Zeitlin, M. F., J. D. Wray, J. B. Stanbury, N. P. Schlossman, Meurer JJ (1982) Nutrition and

Population Growth: The Delicate Balance. Cambridge UK: Oelgeschlager, Gunn and Hain.

FNB/NAS/NRC (1989) Osteoporosis. Chapter 23. In Diet and Health: Implications for Reducing
Chronic Disease Risk. Food and Nutrition Board/National Academy of Sciences/National Research
Council (FNB/NAS/NRC). Washington DC: National Academy Press. 615 - 626.

7.10 SELF-TEST: VII

Test how well you have understood the lecture by answering these questions. Each question is worth 1
mark.

1. Describe the early and middle stages of adulthood

2. Explain the nutrient needs of the following:
 An adult woman
 A man working as a farm labourer

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3. Outline the energy distribution requirements in adults

4. List the nutrients that are required to slow the aging process

5. Explain why a fatty, sugary and salty meal is not recommended especially in middle adulthood

You can now score your performance based on the answers at the back. If you have scored 3 or more,
GOOD! Proceed to lecture eight.
LECTURE EIGHT

8.0 NUTRITION IN THE ELDERLY

8.1 INTRODUCTION

As we grow older, the role of nutrition remains important. Our health and quality of life in later years
depends greatly on what and how we eat. The elderly do not require a special diet, but they do require
the nutrition appropriate for old age. When planning for them, we should include foods that usually suit
their tastes. Nutrition also shouldn't be completely thrown out of balance by going on a restrictive diet,
but instead adapted in response to the changing situations. The best formula for a healthy old age is an
active lifestyle of regular exercise, social interaction, and a balanced, varied diet. As you now know
from the previous lecture, the elderly fall under the category of late adulthood. Late adulthood is the
final stage of physical change and occurs from approximately age 60-65yrs until death.

8.2 LECTURE OBJECTIVES

By the end of this lecture, you should be able to:

 List the nutrition related problems in the elderly

 Discuss the changes in old age/ late adulthood that influence nutrition
 Explain the nutrient requirements of the elderly
 Describe the adjustments that can optimise nutrition in the elderly

8.3 Nutrition related problems in the elderly

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  Osteoporosis
 Obesity
 Anaemia
 Cardio-vascular diseases
 Lowered immunity
 Impaired glucose tolerance
 Malnutrition – drug and / or food induced

8.4 Changes in the aging body

As the human body ages, physiological changes occur slowly in all body systems. These changes are
influenced by nutrition, lifestyle, life events, genetic traits, illnesses and socio-economic factors.
Overall, they impact on nutritional and health status in the following ways:

 They affect food intake and consequently nutrient intake

 They may affect the gastrointestinal tract thus affecting nutrient absorption and digestion
 They may affect the liver thus interfering in the transport, use and storage of some nutrients
 They may affect the excretion of nutrients since kidney function is altered
 They change the nutrient requirements
 Money available to be allocated to food may not be the same as earlier in life

We will now look at these changes.

Sensory Changes

Smell and taste changes- Loss of appetite may lead to disinterest in food. Because of decreased number
of taste buds and smaller olfactory bulbs, food usually seems less palatable (requires more salt and
risking high blood pressure) to the elderly. If food does not taste appetizing or smell appealing or if
they are forced to reduce intake of salt, sugar or fat, they may tend not to eat.

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Sight and peripheral vision usually declines and may lead to less activity. This could affect nutritional
status by leading to fear or inability to cook or read food prices and nutrition labels. This affects
grocery shopping, food preparation and eating.

Loss of or reduced hearing may lead to less eating out or not asking questions of the waiter or grocery
store clerk due to embarrassment.

The sensations of thirst and hunger can also diminish as the body's signals for lack of fluids get weaker
with age.

Structural and functional changes

As the body ages, lean body mass reduces. Reduced muscle mass includes skeletal muscle, smooth
muscle and muscle that affects vital organ function, especially the heart. The most significant result of
the loss of lean body mass may be the decrease in basal energy metabolism. Metabolic rate declines
proportionately with the decline in total protein tissue. To avoid gaining weight, calorie intake should
be decreased or activity increased. Loss of lean body mass also means reduced body water since about
70% of total body water is in lean muscle tissue.

Total body fat usually increases with age with the fat concentrating in the trunk as fat deposits around
the vital organs. However, in more advanced years, weight often declines.

There is thinning of spinal cartilage. This combined with a stooped posture, leads to loss of height, as
the figure below demonstrates.

Fig: 8.1 Loss of height with advancing age

Source: Amarnath.S.S,

In addition, there is loss of bone density. After menopause, women tend to lose bone mass at an
accelerated rate predisposing them to osteoporosis more than men. This makes fractures and their
associated illness and mortality a concern at this age. Vertebral compression fractures can change chest
configuration thus affecting breathing and leading to intestinal distension and internal organ
displacement.

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Motor function is also altered in old age. Reaction time increases and the person needs more time to
perform tasks like dressing, preparing meals, eating, etc.

Organs also change with age. Cardiac output and capacity can be reduced and cardiac function
impaired by chronic diseases like hypertension or diabetes. Kidneys function is impaired, lungs oxygen
uptake is reduced, liver function is impaired, and ability to generate new protein tissue is lowered. The
whole nervous system begins to function more slowly and the brain doesn’t processes information as
well as it used to. The Brain shrinks by at least a third, losing some cell and facing decreased supply of
blood, oxygen and glucose. This makes flow of information to the brain to become slower.

Aging can slow the immune system's response in making antibodies placing them at a risk for
infections. Infections increase nutrient needs and loss.

There is slowing of the normal action of the digestive tract - gastric motility reduces and digestive
secretions diminish, although enzymes remain adequate. Mal-absorption due to degeneration of
intestinal lining also occurs. Since the capacity of the digestive organs decrease with old age, elderly
people are more susceptible to digestive disorders, constipation, diarrhoea, bloating and feelings of
fullness. Eating too little fibre and/ or fluids, habitually eating too large a meal, or eating too fast may
also alter the digestive tract.

The elderly usually lose teeth necessitating dentures. Improperly fitting dentures or lack of dentures due
to inability to afford may change eating habits because of difficulty with chewing. One may lean
towards a soft, low-fibre diet without fresh fruits, vegetables and meat.

Reduced neuromuscular coordination will lead to them avoiding cooking, eating with utensils,
shopping for food and could lead to them choosing food that requires less cooking. It also leads to
reduced activity thus changing nutrient needs and storage. Reduced activity can lead to weight gain,
and a negative effect on retention of calcium in bones.

Psycho-social changes

With the changing social setup, a number of the elderly today find themselves living alone. Their
children could be living in the cities while their spouses could either be dead or separated from them.

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Eating alone could make them loose motivation to cook or eat regular meals. This could mean skipping
meals or not eating a variety of foods.

The elderly usually have long standing food habits that have developed over the years. They include
food likes and dislikes, preparation methods, meal patterns. For instance, an elderly person who has
looked down upon eating vegetables when young is likely to do so even in old age, despite the benefits.
Changing negative habits could be hard and could affect nutritional status.

Nutrition misinformation may lead the elderly to avoid beneficial foods or consume detrimental ones
thus influencing nutritional status. They include beliefs like fruits and milk is for children or the belief
that fatty food and weight gain are healthy.

Living alone could result in feelings of being isolated, abandoned and loneliness leading to stress,
depression and anxiety. These could in turn lead to under or over eating as a way of coping or
opposing. It can also lead to mal-absorption.

Socio-economic changes

A good number of the elderly usually have a reduced economic ability and food security. This is
because of reduced income due to retirement, inability to continue with self employment, inability to
continue with farming activities or the death of a spouse who was supporting them financially. This
reduces their ability to put nutritious food on the table thus affecting their nutritional status.

Age related illnesses and drugs

Conditions like dementia, Alzheimer’s, Parkinson’s disease and Multiple sclerosis affect neurological
function and food intake is altered as a result. The drugs taken to manage them may also affect nutrition
by altering absorption, metabolism and excretion.

Chronic diseases like hypertension, diabetes and other cardiovascular diseases are common in the
elderly. Medications to manage these conditions may affect nutritional status. In addition, they come
with certain dietary restrictions which could alter the overall intake and in turn nutritional status.

8.5 Coping with these changes

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To cope with loss of teeth or improperly fitting dentures, the elderly should begin by having their
dentures adjusted. Food preparation can also be adjusted. One can chop, steam, stew, grind or grate
hard or tough foods to make them easier to chew without sacrificing their nutritional value.

Osteoporosis can be counteracted by a diet high in calcium and weight-bearing exercises. Treatments
like oestrogen replacement, calcium and Vitamin D supplements are also available.

To cope with solitary living and eating, one can try new things to add mealtime sparkle like taking
lunch at the park, treating themselves to a meal out and trying new recipes. One can also get together to
cook and eat with friends and relatives or fellow solitary elderly people.

Variety can be added to food to avoid monotony. Eating the same foods over and over again can lead to
loss of interest in food. Variety can be created in colour, texture and flavour. Flavour can be varied
using spices, new foods and herbs/ ingredients. One can also eat frequent smaller meals.

To cope with financial constraints, planning is important- preparing a shopping list. Processed and
ready-made foods are more expensive than fresh meats, vegetables, milk and eggs. One can also take
advantage of low prices by picking foods in season and looking out for discounts. Buying items in bulk
also ensures savings.

When the sensations of hunger and thirst diminish, one can use outside reference points and signals to
guide him or her (time of day, people they live with, etc.). Eating and drinking should therefore be
scheduled. It's useful to develop a pattern for eating and taking water, with several small meals spread
out over the day.

Digestive issues like constipation, diarrhoea, bloating and feelings of fullness can be dealt with by
balanced nutrition, eating fibre-rich foods such as whole-grain products and fruits and vegetables, and
by drinking plenty of fluids. To counteract diarrhoea, foods like bananas, paddy rice, black tea, dark
chocolate and white bread are helpful. Proper chewing of food and taking several small meals a day
should also help. Exercise and abdominal massage also keep the intestines moving.

Enriched foods and supplements together with a healthy diet helps meet daily nutrient requirements.

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Regular exercise has several benefits. It prevents muscle deterioration, promotes mental equilibrium,
and helps prevent chronic diseases. One can engage in walking, swimming, cycling, gym work-outs,
hiking, etc. Another benefit is in outdoor exercise as it builds up vitamin D from the sun. Energy
consumption is also raised by regular exercise, and this has a beneficial effect on weight. People who
exercise regularly can also eat more, and this makes it easier to meet daily vitamin, mineral, and trace
elements requirements. To fight depression, stress and anxiety, exercise generally lifts the mood.
Through strength training exercises, the elderly are able to increase their strength, increase their
independence and mobility and regain once-lost abilities to perform daily tasks.

Generally, the elderly should:

 Eat plenty of fruits, vegetables and whole-grain products

 Take one protein-rich food daily
 Drink plenty of liquids
 Engage in regular physical activities
 Maintain a steady weight (BMI under 25), lose excessive weight (BMI > 30)

8.6 Specific Nutrient Modifications

Calories: Caloric needs reduce due to more body fat, less lean muscle and reduced activity. The
challenge for the elderly is to meet the same micro-nutrient needs as when they were younger, yet
consume fewer calories. They should choose "nutrient-dense" foods in relation to their calories. For
example, low-fat milk is more nutrient dense than regular milk since its nutrient content is the same,
but it has fewer calories because it has less fat. About 60 percent of calories should come from
carbohydrates, with emphasis on complex carbohydrates. Glucose tolerance may decrease with
advancing years. Complex carbohydrates put less stress on the circulating blood glucose than refined
carbohydrates.

Fats: Reducing the overall fat content in the diet is recommended because of chronic diseases. Besides,
it is the easiest way to reduce caloric intake. Saturated fat (animal fats) should particularly be restricted.
For people above the age of 75, fat restrictions are less likely to be beneficial. In addition, fat restriction

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is not appropriate for those who have suffered weight loss or have little appetite. In fact for them,
additional fat may be used to boost the caloric intake.

Fibre: Many elderly people have problems of constipation and bowel problems because of reduced gut
motility and inactivity. Adequate fibre and plenty of fluids help maintain normal bowel function. Fibre
also reduces the risk of intestinal inflammation. Excessive amounts of very high-fibre foods are
however also nor recommended since they are too bulky and may interfere with the absorption of some
nutrients. Consumption of cereal foods, fruit and vegetables should be encouraged to ensure adequate
fibre.

Protein: Protein needs usually do not change as our years advance. Protein absorption may decrease as
we age, and our bodies may make less protein. However, this does not imply that protein intake should
be increased, because kidney function declines and excess protein could stress the kidneys. Protein
deficiency on the other hand can lead to nutritional deficits. Protein is important for the development
and regeneration of body cells, especially the muscles.

Vitamins and Minerals

Illness stresses the body and may use up whatever stores there are, making the person vitamin deficient.
Medications also interfere with many vitamins and minerals. Eating nutrient-dense foods becomes
increasingly important when calorie needs decline but vitamin and mineral needs remain high. Since
the body can store fat-soluble vitamins, the elderly are at lower risk of fat-soluble vitamin deficiencies.

Iron: Anaemia is a common problem in the elderly. Poor dietary intake, absorption, use of some drugs
and blood loss are often the causal factors. Adequate iron can be sourced from red meat and non-meat
sources daily. Absorption is improved by consuming vitamin C-rich foods along with meals, like fruit
juice or fresh fruit or vegetables.

Zinc: Zinc is important for a healthy immune system and wound healing. Many of the elderly suffer
from pressure ulcers. It also improves taste acuity in people where stores are low. Together with
vitamins C and E, and the phytochemicals lutein, zeaxanthin and beta-carotene, zinc may help prevent
or slow the onset of age-related macular degeneration. To obtain these nutrients, one should consume at

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least five servings of fruits and vegetables, especially dark green, orange and yellow ones. Good
choices include kale, spinach, broccoli, peas and oranges.

Vitamin E: Studies show that eating foods rich in vitamin E, like whole grains, nuts, vegetable oils and
seeds, may help reduce the risk of Alzheimer's disease. However, the same benefits are not enjoyed
with vitamin E from supplements.

Calcium and Vitamin D: Adequate intakes of calcium help maintain bone strength by slowing the rate
of calcium loss from bones, which begins after the age of 30 and accelerates in later years, especially in
women. If bone density decreases, osteoporosis (bone loss) develops over time. Bone degeneration is
not only due to calcium deficiency but also partly to genetics. The elderly need about 1,000 mg of
calcium a day. Vitamin D is required for calcium metabolism and its deficiency in elderly people can
lead to bone softening and distortion. Adequate outdoor exercise is also helpful. Post-menopausal
women may need a calcium supplement if they can't get enough from the diet.

Vitamin B12: Low levels of the vitamin have been associated with age-related hearing and memory
loss. Normally, the body gets vitamin B12 by separating it from protein in food during digestion,
enabling it to be absorbed through the intestines. But many of the elderly suffer from atrophic gastritis
which causes an increase in bacteria in the stomach and small intestine. These bacteria can interfere
with the body's ability to absorb vitamin B12. Many elderly people therefore, need to take in extra
vitamin B12.

Folate: Vitamin B9 is related to B12 metabolism in the body and is believed to improve hearing.
However, if B12 levels are not adequate, high folate levels may be a health concern. As we age, the
amount of folate needed to absorb vitamin B12 decreases. The concentration of homocysteine in the
blood rises as the body's folate levels go down. High homocysteine levels are a risk factor for heart
attack, peripheral vascular disease and stroke.

Vitamin A: The carotenoid, leutein, found in dark green leafy vegetables like spinach, is believed to
decrease the risk of the chronic eye disease macular degeneration.

Water/ Fluids: Adequate water intake reduces stress on kidney function. As we discussed earlier in this
lecture, kidney function declines with age. Adequate fluid intake also eases constipation. With the

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aging process, the ability to detect thirst declines, and so the elderly should not wait to drink water until
they are thirsty but should make it a habit to drink plenty of fluids.

8.7 SUMMARY

By now you should know that:

The elderly experience deterioration in sight and peripheral vision, hearing, smell and taste, which
affect nutritional intake and health status.

Chronic diseases like hypertension or diabetes are also common in this age group thus reducing the
overall fat content in the diet is recommended.

Aging can slow the immune system's response in making antibodies.

Metabolic rate declines proportionately with the decline in total protein tissue thus reduce calorie intake
or increase activity.

They lose bone density. Women tend to lose bone mass at an accelerated rate after menopause thus
predisposing them to osteoporosis. Adequate intakes of calcium help maintain bone strength by slowing
the rate of calcium loss from bones.

Digestive secretions diminish markedly, although enzymes remain adequate. Adequate dietary fibre and
fluid help maintain regular bowel function without interfering with the digestion and absorption of
nutrients.

Calorie needs change (reduce) due to more body fat, less lean muscle and reduced activity.

Anaemia is usually common in this age group.

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8.8 ACTIVITY

Interview a senior citizen (your grand parent, neighbour, friend or other relative) on his or her former
and new experiences as their age has advanced. Discuss experiences with food, eating, digestion,
cooking, appetite, and your own curiosities related to nutrition.

8.9 FURTHER READING

Olson. R, (1988). Nutrition and aging. Twelfth Maribou symposium, Nutrition reviews 46:38

8.10 SELF-TEST: VIII

You can now answer each of the following questions. Each correct answer is worth 1 mark.

List 4 nutrition related problems in the elderly

Citing specific changes, explain how the sensory changes in the elderly influence nutrition

Justify the nutrient requirements of the elderly for:

 Calories
 Calcium
 Iron

Describe the adjustments that one can make to optimize nutrition and cope with the changes in the
elderly

Identify two dietary components that would help cope with constipation in the elderly

Award yourself points by checking the answers at the back. If you have scored 3 or more, you are ready
to proceed to the final lecture in this unit- nutrition in special needs.

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LECTURE NINE

9.0 NUTRITION DURING SPECIAL NEEDS

9.1 INTRODUCTION

In this lecture, we will discuss nutrition during special needs. We will look at:

- Nutrition in vegetarians

- Nutrition and Food allergies and food intolerances

- Nutrition and alcohol abuse

- Nutrition and HIV and AIDS

- Nutrition in resource limited settings

9.2 LECTURE OBJECTIVES

By the end of this lecture, you should be able to:

- Discuss the nutritional concerns in vegetarian diets

- List and differentiate food allergies and food intolerances

- Explain the nutritional implications of alcohol abuse

- Outline the nutrient needs of people living with HIV and AIDS

- Discuss the feeding options for infants born to mothers living with HIV and AIDS

- Describe the nutrition challenges in resource limited settings, and possible interventions

9.3 NUTRITION AND VEGETARIANISM

A vegetarian is a person living on a diet of grains, pulses, nuts, seeds, vegetables and fruits, with or
without the use of dairy products and eggs (preferably free range). A vegetarian does not eat any meat,
poultry, game, fish, shellfish or slaughter by-products. A vegan does not eat all animal products
including honey. Ovo-lactovegetarians eat only milk and eggs from animals, ovo-lacto-pollovegetarian

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 eat milk, eggs and poultry in their diets while the pesco-vegetarian eat fish but no other food of animal
origin.

9.3.1 Benefits of vegetarianism

 Reduction in risks of suffering from heart disease as a result of lower blood cholesterol amongst
vegetarians.
 Reduction of the risk of suffering certain cancers. Meat eating has been identified as a possible dietary
risk factor in prostate, pancreas, colorectal and lung cancers.
 Lower blood pressure.
 Less chance of becoming overweight or obese since they gain a lower proportion of their energy from
fat.
 Vegetarians are also less likely to suffer from gallstones, appendicitis and food poisoning.

9.3.2 Nutrients of concern in vegetarianism

Although the inclusion of animal products does not guarantee the adequacy of a diet, it is easier to
select a balanced diet with animal products than without them. Meat and fish are important sources of
protein, readily absorbed haem-iron, zinc, thiamin, riboflavin, niacin and vitamin B12. In a vegetarian
diet, these nutrients must come from other sources. The main area of concern regarding vegetarian diets
is the small but significant risk of nutritional deficiencies. These include deficiencies of iron, zinc,
riboflavin, vitamin B12, vitamin D and calcium (especially in vegans) and inadequate energy intake.

These deficiencies are highest in those with increased requirements. These are:

 Infants
 Children
 Adolescent girls
 Pregnant and lactating women

Vegan diets may have serious adverse effects on infant development and should be discouraged as they
carry a high risk of nutrient deficiencies and have been associated with protein–energy malnutrition,
rickets, growth retardation and delayed psychomotor development in infants and children. Such diets
are not recommended during the complementary feeding period.

Calories and Fat: A diet with lots of fresh fruits, vegetables, and whole grains is high in fibre. Young
children have small stomachs and eating high fibre foods may lead to them not getting adequate
calories. To achieve adequate amounts of calories for the vegetarian growing age groups (children and
adolescents), foods like avocado, nuts and seed butters, dried fruits, and soy products can pack a lot of

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 calories into small quantities. To promote linolenic acid intake, include foods like canola oil, flaxseed
oil, and soy products in the child's diet

Protein: The risk for protein deficiency is usually increased in vegetarian diets because:

 Some of the protein that would normally be used for growth is diverted to be used as energy in high
fibre low energy diets
 Plant foods mostly have incomplete protein (do not have all the essential amino acids) and if not well
mixed, can lead to growth deficits.

The vegetarian diet must thus be made up of a good combination of plant proteins to stimulate a
complete protein. For adults, protein from two or more plant groups daily may be sufficient. For
children, however, and especially those aged 6–24 months, each meal should contain two
complementary sources of plant protein.

Iron: Fibre, oxalates and phytates in plant foods reduce the bio-availability of non-haem iron.
Vegetarians’ iron sources are mainly non-haem iron. They are thus prone to iron deficiency anaemia.
Taking of meals along with Vitamin C rich foods is recommended to improve absorption.

Calcium: This is of particular concern for those who do not take dairy products. In addition, plant foods
have compounds that inhibit calcium absorption. Eggs, cheese and milk all provide high-quality protein
and are also a good source of the B group vitamins and calcium.

Zinc: Zinc is mainly obtained from animal foods and may thus be inadequate in a vegetarian diet.

Vitamin D: This is especially important for those who do not consume dairy products and do not get
frequent exposure to the sun. A supplement and vegetables rich in the vitamin are recommended.

Vitamin B12: It is found primarily in meat, eggs and dairy produce, which are of animal origin.
Fermented soya products and seaweeds also have significant levels. Vegans will only be able to obtain
vitamin B12 from fortified foods or a nutrient supplement. Problems may occur as a result of
complementary diets containing no animal products (thus no milk), particularly during late infancy and
early childhood when the breast milk supply may be little. Vitamin B12 is essential for growth and thus
a deficiency will lead to growth deficits in children.

A vegetarian diet is can be a healthy diet if well balanced. The food wheel overleaf can be a guide on
how to achieve this balance thus reducing the risks for developing the above deficiencies. Ensure that
your daily intake includes:

Fig: 9.1 The food wheel

 5 servings of fruit and vegetables daily

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  5 servings of bread, cereals and potatoes daily
 2-3 servings of protein rich foods daily
 2-3 servings of milk and dairy products daily
 Moderate amounts of fats and sugar

9.3.3 Anti- nutrients in vegetarian diets

Oxalic acid: Interfere in the absorption of iron and calcium by forming insoluble complexes with them.

Phytic acid: Interfere in the absorption of iron zinc, copper and calcium by forming insoluble
complexes with them.

Poly-phenols: Interfere in the absorption of iron and the macronutrients- protein, lipids and starch. An
example is tannins.

Dietary fibre: High amounts interfere in the absorption of iron and other micronutrients by binding
them, decreasing intestinal transit time and making them physically unreachable due to bulk.

Goitrogens: These prevent the intestinal reabsorption of thyroxine, resulting in hypertrophy of the
thyroid gland

Protease inhibitors: They inhibit the action of digestive enzymes thus decreasing protein digestion

Lectins: E.g in foods like soy bean interfere in the absorption of carbohydrates.

9.4 NUTRITION AND ALLERGIES AND FOOD INTOLERANCE

Adverse reactions to food affect a small but significant percentage of the population with symptoms
ranging from mild to severe and life threatening. These reactions are mainly divided into two groups:

iv. True food allergies- an abnormal immunological response to a food or food component, mostly a
naturally occurring protein. There are two types of food allergies- anti-body mediated (immunoglobulin
E) food allergies for instance peanut and cow milk allergies; and cell mediated (T lymphocytes) food
allergies for instance celiac disease.

Immunoglobulin E (IgE) mediated food allergies are most likely to occur in infants born to parents with
a history of allergic disease (pollen, spores, food, bee venom). Celiac disease is also inherited.

ii. Food intolerances- do not involve abnormal immunological mechanisms. These are categorised into 2-
metabolic food disorders and idiosyncratic reactions.

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 Unlike in food allergies where small amounts can trigger a reaction, individuals with food intolerance
can tolerate some amount of the trigger foods in their diet. Metabolic food disorders occur due to
genetically determined metabolic deficiencies that either affects the ability to metabolize a specific food
substance or increase the sensitivity to the trigger chemical in the food. Examples include lactose
intolerance,galactosemia, alkaptonuria (anomalies of tyrosine metabolism), hemochromatosis,
hyperparathyroidism, metabolic acidosis, cirrhosis and hyperlipidemia. Lactose intolerance is among
the common types of food metabolic disorders, especially in Africans. It is due to a deficiency of the
enzyme lactase in the intestinal tract leading to inability to metabolise lactose from milk and dairy
products. Food idiosyncrasies are adverse reactions to food or food ingredients that occur through
unknown mechanisms. Examples include sulphite induced asthma and aspartame in migraine and
urticatia.

9.4.1 Allergenic foods and food ingredients

Food allergens are almost always naturally occurring proteins. Foods may contain both major and
minor allergens. Major allergens are those that bind to serum IgE antibodies from more than half the
patients with specific food allergies. IgE mediated food allergies most common worldwide are mainly:

 Cow milk
 Eggs
 Fish
 Crustacea (crab, shrimp, lobster)
 peanuts
 soy beans
 Tree nuts (almonds, walnuts, hazelnuts)
 Wheat

Celiac disease is a mal-absorption syndrome in sensitive individuals that occurs when they consume
wheat, barley, rye, etc. The main allergens are gliadin and gluten. The allergen leads to mucosal damage
in the small intestine resulting in nutrient mal-absorption. This coupled with the ongoing inflammatory
processes cause the symptoms.

9.4.2 Symptoms of food allergies and food intolerance

IgE mediated food allergy symptoms include nausea, vomiting, diarrhoea, abdominal cramping,
eczema, asthma, laryngeal oedema and anaphylactic shock, while Celiac disease symptoms include
vomiting, diarrhoea, bloating, weight loss, anaemia, weakness, muscle cramps, weight loss, chronic
fatigue and bone pain. In children, failure to gain weight and growth retardation is common. Lactose
intolerance symptoms include abdominal discomfort, flatulence and frothy diarrhoea.

9.4.3 Management of food allergies and food intolerance

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 The best management strategy for people with food allergies and food intolerance is dietary restrictions
where you avoid a diet containing the triggers. E.g. avoiding dairy products for lactose intolerant
individuals, avoiding wheat products for those with celiac disease.
 Breastfeeding for extended periods of time delay IgE mediated food allergies. However if the allergens
are present in breast milk (from lactating mother’s diet), it can lead to sensitisation in the infant e.g.
peanut is a common culprit.
 Use of pro-biotic during lactations reduces likelihood of allergenic sensitisation. They also reduce
metabolic disorders like lactose intolerance.
 Use of hypoallergenic infant formula may prevent the development of the allergies
 Processing of foods to extract or remove the allergenic ingredient. E.g removal of gluten in wheat
products for celiac disease.
 Pharmacologics likes antihistamines are used to manage the symptoms if one is exposed.

9.5 NUTRITION AND ALCOHOL ABUSE

Alcohol is a significant aspect of many people’s daily lives. However, alcohol abuse can undermine
nutrition and health status.

9.5.1 How alcohol affects nutritional status

Alcohol affects nutrition in different ways. Depending on the type, alcohol may contribute nutrients in
the diet. These include calories, magnesium, phosphorus and some vitamins. On the other hand, alcohol
negatively impacts on nutritional status in the following ways:

 It may displace food in the diet thus affecting nutrient intake

 It may affect food intake by depressing the appetite
 It may affect the gastrointestinal tract thus affecting nutrient absorption and digestion
 It may affect the liver (liver disease and fatty liver) thus interfering in the transport, use and storage of
some nutrients
 It increases the excretion of nutrients in urine and bile
 It increases nutrient requirements due to increase in metabolic rate
 Money spent on alcohol may also reduce money allocated for food

9.5.2 Effects of alcohol abuse on specific nutrients

Lipid: Excess alcohol reduces lipid oxidation leading to hyperlipidemia and high levels of very low
density lipoprotein levels. This leads to a fatty liver from alcoholic liver disease. Moderate intake of

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 alcohol on the other hand enhance levels of high density lipoprotein thus is protective against cardio-
vascular disease.

Carbohydrate: Excess alcohol intake is associated with alcoholic pancreatitis leading to exocrine
pancreatic insufficiency with maldigestion and malabsorption. Heavy drinkers with inadequate
carbohydrate diet are usually at risk for hypoglycaemia due to reduced gluconeogenesis. Alcohol also
inhibits the storage of glycogen.

Vitamin A: Chronic alcohol intake may reduce Vitamin A levels in the blood. Retinol-binding-protein
that transports vitamin A is also reduced.

Vitamin D: Alcohol reduces vitamin E levels, especially after chronic intakes.

The B Vitamins: Excess alcohol causes thiamine deficiency and a syndrome called Wernicke-Korsakoff.
It affects thiamine by causing malabsorption and by reducing intake. There is also increased loss of the
vitamin in urine. Thiamine storage is also reduced in heavy drinkers due to liver and muscle problems.
Riboflavin deficiency is common in alcoholics due to low intakes and decreased bioavailability.
Alcohol also inhibits transformation and activation of the vitamin in the peripheral tissues and during
absorption. For vitamin B6, alcohol reduces its formation to the active form and increases urinary loss.
Another deficiency common in alcoholics is folate. Alcohol degrades the vitamin, impairs its
metabolism and increases the urinary losses.

Calcium: In heavy drinkers, there is reduced intake and increased urinary losses. Alcohol leads to
mucosal damage and reduces Vitamin D levels thus affecting calcium absorption.

Magnesium: Heavy alcohol intake leads to reduced serum and cell levels of magnesium. This is due to
reduced intake, malabsorption and increased faecal and urinary losses.

Zinc: Due to reduced intake, malabsorption, increased urinary losses and an alteration of zinc
distribution, heavy alcohol intake reduces zinc serum and hepatic levels.

9.5.3 Intervention programs

Prevention strategies are more useful due to the grave consequences of alcohol abuse on health.
Corrective measures are dependent on the nutrient in question and the individual. To mitigate the
effects of alcohol abuse on nutritional status, the following are generally suggested:

 The most significant intervention would be to permanently tackle the alcoholism/ alcohol abuse
through treatment, counselling, therapy and/ or rehabilitation, depending on its severity and the
individual
 Immunisation/ supplementation of alcoholics with nutrients at regular intervals. This is not advisable
for vitamin A. Supplementation with vitamin B6 is also not useful if the individual still continues to
drink heavily.
 Fortification of alcoholic drinks with nutrients

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 Making nutrient-impregnated snacks available on bar counters
 Nutrition education to encourage adequate dietary intake and diversification

9.6 NUTRITION AND HIV AND AIDS

9.6.1 Nutrition for infants born to HIV positive mothers

The risk of Mother-to-child transmission of HIV is increased by vitamin A deficiency, breast

conditions- cracked or bleeding nipples, breastfeeding and duration of breastfeeding - an infant
continues to be exposed to the risk of HIV transmission for as long as he or she is breastfed. The longer
the duration of breastfeeding, the longer the infant is exposed to the risk of HIV infection.

9.6.1.1 Feeding options for HIV-positive mothers

Breastfeeding is normally the best way to feed an infant. However, if a mother is infected with HIV, it
may be preferable to replace breast milk to reduce the risk of HIV transmission to her infant. The risk
of replacement feeding should be less than the potential risk of HIV transmission through infected
breast milk, so that infant illness and death from other causes do not increase; otherwise there is no
advantage in replacement feeding. The options for feeding the infant are:

 Exclusive breast feeding for six months then weaning and no longer breastfeeding. After six months of
age, replacement feeding should preferably continue to include a suitable breast-milk substitute. In
addition, complementary foods made from appropriately prepared and nutrient-enriched family foods
should be given three times a day. If suitable breast-milk substitutes are not available, replacement
feeding should be with appropriately prepared family foods which are further enriched with protein,
energy and micronutrients and given five times a day. Micronutrient supplements should also be given
if available.
 Modified breastfeeding- Early cessation of breastfeeding reduces the risk of HIV transmission by
reducing the length of time for which an infant is exposed to HIV through breast milk. It is advisable
for an HIV-positive woman to stop breastfeeding as soon as she is able to prepare and give her infant
adequate and hygienic replacement feeding. The most risky time for artificial feeding in environments
with poor hygienic conditions is the first two months of life, and family circumstances will therefore
determine when the mother is able to stop breastfeeding and start replacement feeding. Early cessation
of breastfeeding is also advisable if an HIV-positive mother develops symptoms of AIDS. Types of
modified breastfeeding are:

i. Expressed and heat-treated breast

milk- Heat treatment of expressed
breast milk from an HIV-positive
mother kills the virus in the breast
milk but reduces the levels of the
anti-infective factors.

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 ii. Breast-milk banks- In some areas, milk is available from breast-milk banks. Breast-milk banks are
generally used as a source of breast milk for a short time, for example, for sick and low-birth-weight
newborns. They are not usually an option for meeting the nutritional needs of infants for a long period.
It is important to ensure that donors are screened for HIV and that the donated milk is correctly
pasteurised.
iii. Wet-nursing- In some areas there is a tradition of wet-nursing where a relative breastfeeds an infant.
However, there is a risk of HIV transmission to the infant through breastfeeding if the wet-nurse is
HIV-infected. There is also a potential risk of transmission of HIV from the infant to the wet nurse,
especially if she has cracked nipples.

 Breast-milk substitutes – these are :

- Commercial infant formula when the family has reliable access to sufficient formula for at least six
months and when the family has the resources - water, fuel, utensils, skills and time — to prepare it
accurately and hygienically.

- Home-prepared formula- Home-prepared formula can be made with fresh animal milks, with dried
milk powder or with evaporated milk. Micronutrient supplements are recommended, as animal milks
may provide insufficient iron, zinc and may contain less vitamin A, C and folic acid. If micronutrient
supplements are unavailable, complementary foods rich in iron, zinc, vitamin A and C and folic acid
should be introduced at four months of age. However, it is unlikely that they will provide sufficient
amounts of the required nutrients.

- Modified animal milks- Cow’s milk has more protein and a greater concentration of sodium,
phosphorous and other salts than breast milk. Modification involves dilution with boiled water to
reduce the concentration. Dilution reduces the energy concentration so sugar must be added. Goat’s and
camel milk are similar in composition to cow’s milk and so needs to be modified in the same way. They
are deficient in folic acid which infants need to be given as a micronutrient supplement. Both sheep and
buffalo milk have more fat and energy than cow’s milk. The protein content of sheep milk is very high.
Using either for infants would therefore require more dilution than cow’s milk.

- Dried milk powder and evaporated milk- Home-prepared formula could be considered as an option by
HIV-positive women when commercial infant formula is not available or is too expensive for the
family, the supply of animal milk or other milk is reliable and the family can afford it for at least six
months, the family has the resources to prepare it hygienically and can make the required modifications
accurately and micronutrient supplementation is possible.

- Unmodified cow’s milk- During the first few months of life, feeding with unmodified cow’s milk can
cause serious problems, particularly if the infant becomes dehydrated. Infants need to be offered extra
water (that has been boiled and cooled) and monitored carefully for dehydration if they have fever,
respiratory infection or diarrhoea. To ensure that the infant gets enough milk and that water does not
displace milk, drinks of water should be offered after feeds. Unmodified cow’s milk could be
considered as an option by HIV-positive women when commercial infant formula is not available or is
too expensive for the family to buy and prepare; the supply of cow’s milk is reliable and the family can

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 afford it for at least six months; the family lacks the resources; time and fuel to modify cow’s milk to
make home-prepared formula and micronutrient supplementation is possible.

9.6.2 Nutritional recommendations for adults living with HIV and AIDS

Dietary changes for the person living with HIV and AIDS should aim at improving weight, nutrient
stores and diet and eating habits, taking multivitamin supplements if diet is not adequate and promoting
hygiene and food safety to avoid pathogenic contamination and diarrhoea.

9.6.2.1 Recommendations for nutritional support for HIV-positive asymptomatic individuals:

A healthy diet that is adequate in terms of energy, protein, fat and other essential nutrients is important.
Locally available foods should be identified. The following adjustments are recommended.

 Increase energy quantities by 10-15%

 For the general female population the RDAs recommend 48 to 60 grams of protein per day for a 60 kg.
Female. For the HIV population it recommends 72 – 120 grams per day thus the protein is increased
depending on the body weight.
 For antioxidants, take 5,000 to 10,000 IU per day of vitamin A, 50,000 – 100,000 IU per day for B
carotene, 200 – 500 mg per day for vitamin C, 100 – 200 micro-grams per day of selenium.
 For the B complex Vitamins they should increased 2 to 5 time the RDA. For Niacin B 3 38 – 95 mgs is
adequate, for thiamine B1 3.0 – 7.5 mg, Riboflavin B2 3.4 - 8.5 mg, Pyridoxine B6 4.0 – 10 mg and 4.0
– 10 micro grams for Cobalamin B12.
 For n-3-Fatty acids, 1-2g per day is recommended, but not levels above 10 gms per day.

A nutritionist should review the patient’s total dietary pattern and food group intake to identify possible
inadequacies. Re-evaluate food and supplement recommendations every 6 months, and determine
serum vitamins B1, B6, B12, and A, and selenium (If using supplements) on a yearly basis.

9.6.2.2 Recommendations for nutritional support for people with AIDS:

At the AIDS stage, the nutritional advice is similar to those of the asymptomatic individuals except that
the emphasis should shift from preventing to mitigating the nutritional consequences of the disease and
to preserving functional independence where possible. The foods taken should help increase appetite,
be easily digestible and promote and maintain weight gain. To maintain weight and avoid loss of
muscle mass, it is recommended that small amounts of low-fat foods should be taken frequently to
ensure better digestion and nutrient absorption. Variety in food types should be taken and even larger
portions when one is recovering from an illness. Smoking and alcohol should be avoided. A body mass
index of 18.5 kg/square meter or more should be maintained and physical activity encouraged to build
muscles and increasing energy. The drug-food interactions should also be considered.

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Overleaf, AIDS symptom and illness related management is outlined.

Table 9.1: Practical suggestions on how to maximize nutritional care during and

following HIV and AIDS related symptoms and illnesses.

Illness or symptom Nutrition practices

Eat small portions of food, especially of favorite fo
and texture.
Eat nutritious snack often.
Anorexia (loss of Drink liquids often.
appetite) Avoid strong smelling foods.
Select more energy and protein foods.

Drink plenty of clean water and other fluids like jui

But avoid strong citrus juices.
Consume foods rich in fiber.
Eat starchy foods like rice, cassava and maize.
Consume fermented foods like porridge and yoghur
Eat soft fruits like mashed bananas, potatoes, carrot
Diarrhea Observe hygiene in food preparation and service
visiting the toilet.
Reduce fatty foods intake, drink non-fat milk and
and extra oils.
Limit gas forming foods like cabbages, onions and c
Avoid caffeine and alcohol.

Drink lots of fluids e.g. soups, lemon and gum tre

energy and nutrients.
Fever Bathe in cold water and rest adequately.

Nausea and vomiting Eat foods like soups, unsweetened porridge and frui
Eat lightly salty and dry plain foods like crackers.
Avoid spicy and fatty foods and caffeine and alcoho
Drink liquids like clean water.
Drink herbal teas, warm lemon juice and ginger roo
Avoid strong smelling foods.
Take simple boiled foods.

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 Avoid large meals but take small snacks throughout
Eat small frequent meals and rest between meals.

Eat cold or room temperature foods.

Avoid sugary and very sweet foods since they cause
Eat thick smooth foods such as porridge, puddin
foods.
Thrush (sore mouth Avoid citrus fruits like lemons and tomatoes an
and throat) foods.
Drink high energy and high protein liquids with a st
Avoid alcohol.
Mouth should be rinsed after eating.

Take iron supplements.

Eat more iron-rich foods such as animal products,
Anemia legumes, nuts, fortified cereals and fruits.
Treat causative factors like malaria or hookworm.

Increase food intake in terms of quantity and fre

Increase amounts of protein and starches.
Muscle wasting Use fortified foods.
Improve quality of foods taken by providing a varie

Eat more foods that are high in fiber like maize, v

skins.
Constipation Drink plenty of liquids.
Avoid processed or refined foods.

Eat small frequent meals.

Drink fluids.
Bloatedness or Avoid gas forming foods like cabbages and soda.
heartburn Eat long before sleeping to allow for digestion.

Consume foods high in protein, energy, iron and vit

Tuberculosis Consult doctor about food and drug interaction advi

Use flavor enhancers like salt, spices, herbs and lem

Loss of taste and /or Chew food well and move around the mouth to stim
abnormal taste

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 9.6.2.3 Nutrition Recommendations for Pregnant HIV positive women

Optimal antenatal and postpartum care should be provided to the HIV positive pregnant women. The
nutritionist should ensure adequate weight gain during pregnancy and give iron-folate supplements and
other nutritional supplements, where available.

Prompt treatment of all conditions that affect food intake or increase the risk of mother to child
transmission should be done and ARV drugs provided, if available.

The women should be fully informed about infant feeding options and risks, supported in feeding
decisions and breastfeeding mothers provided with nutritional support.

9.6.2.4 Food safety recommendations

To avoid diarrheal diseases, the person preparing the food should ensure they:

 Keep their hands clean

 Food preparation is done in areas clean
 Separate raw foods from cooked foods and utensils used with them
 Cook fresh and reheated foods thoroughly
 Keep food at safe temperatures
 Use safe water and raw materials

9.7 NUTRITION IN RESOURCE LIMITED SETTING

Nutritional status is a result of processes and structures in a society that regulate access to resources,
education, economic assets, and opportunities. The effects of early childhood malnutrition persist into
the school years and even adulthood, lowering productivity and quality of life. Small adult women who
were malnourished as children are more likely to produce small babies, and the cycle of malnutrition
and illnesses continues. Chronic under nutrition leads to lower productivity and in turn, enormous long-
term economic costs to society. Research has shown that men who were better nourished at age 0-2
years earn more later in life, thus good nutrition can drive economic growth. The cost of preventing
malnutrition is also much less than the costs of its consequences. Moreover, good child nutrition
contributes to good mental capacity of the society, which is an important element for a society to
develop in all aspects (socially, economically, environmentally). Under nutrition causes productivity
losses in adulthood, leading to lower cognitive and physical abilities. This affects the individual’s
income earning potential for life, making it difficult to rise out of poverty. The world’s poor bear the
greater burden of malnutrition. In resource limited settings therefore, it makes sense to tackle
malnutrition.

9.7.1 Characteristics of the resource limited environment

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 Most resource limited settings have negative environmental characteristics that affect the nutritional
status of the community both directly and indirectly. They affect the nutritional status by impacting on
food intake, or exposing the individual to unhealthy factors that promote loss or limited utilisation of
nutrients. They include:

 Inadequate food
 Inadequate maternal and child care practices.
 Poor access to safe water and sanitation
 Inadequate health services
 Limited schooling opportunities
 Limited income generating opportunities
 Inadequate, crowded housing

9.7.2 Nutrition problems in resource limited setting

These include:

 Food insecurity
 Protein-energy malnutrition
 Vitamin A deficiency
 Iron deficiency
 Iodine deficiency disorders
 Rickets – Calcium and/ or Vitamin D deficiencies
 Zinc deficiency

There is need to initiate interventions that focus on the essential nutrition actions to protect, promote,
and support the following priority nutrition outcomes:

 Exclusive breastfeeding for at least six months

 Adequate complementary feeding starting at about six months with continued breastfeeding for two
years
 Appropriate nutritional care of sick and malnourished children
 Adequate intake of vitamin A for women and children
 Adequate intake of iron for women and children
 Adequate intake of iodine by all members of the household.

Other important actions in the resource limited setting are:

 Promotion and support of the care and nutrition of adolescent girls

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 Appropriate nutritional information, education and training to relevant professionals, care givers and
organisations on community nutrition
 Ensuring older people’s access to appropriate nutritious foods and nutritional support
 Families with chronically ill members, including people living with HIV and AIDS, and members with
specific disabilities have access to appropriate nutritious food and adequate nutritional support
 Community-based systems that ensure appropriate care of vulnerable individuals

9.7.3 Criteria for interventions in a resource limited setting

 Should be cost effective and affordable

 Should empower the target population
 Should reduce inequalities within the population
 Should be sustainable
 Should be allow for participation
 Should offer possibilities for integration into existing services and systems

9.7.4 Some interventions to improve nutrition in resource limited settings

 Food security programs- targeting primary production. E.g. Distribution of farm inputs (seeds, tools and
fertiliser, fish nets and gear, and livestock fodder and nutritional supplementation), agricultural
extension services and possibly technical training.
 Poverty reduction programs and livelihood security programs- Income and employment strategies like
Cash-for-work, Food-for-work, Micro-finance and income generating schemes. This also needs an
element that supports the people in the management, supervision and implementation of their
businesses e.g.; through entrepreneurship education.
 Supplementation programs- nutrient supplements and food supplements e.g. food aid, routine Vitamin
A supplementation of under fives every six months.
 Nutrition information, education and communication- e.g. nutrition education, promotion and
counselling of specific themes like infant and young child feeding, and dietary diversification.
 Public health interventions- Improving access to health care, sanitation and potable water,
immunisation, provision of essential drugs, provision of mosquito nets, and deworming.
 Empowerment programs- focusing on improving livelihoods of the vulnerable (women, children,
people living with HIV and AIDS)
 Therapeutic care- of the severely malnourished through 24-hour in-patient care, day care and home-
based care.
 Research- it is important to do studies on the local foods and come up with drought resistant and
nutrient dense foods.

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 9.7.5 Community Based Health Care

Many poor communities are disengaged from the formal health system (In Sub-Saharan Africa 53% of
the poorest households do not seek care outside the home). Barriers include medical fees, distance to
facilities, traditional beliefs and the perception of the skills and attitudes of health workers. In resource
limited settings, the cost and access to health care remain major problems. Health workers are few and
concentrated in cities. Health systems remain very weak in these areas, thus exposing the population to
ill health and nutrition.

One possible solution to this problem is Community Based Health Care (CBHC). CBHC is defined as
an integrated system of care designed to meet the health needs of individuals, families and communities
in their local settings. The goal is to ensure better accessibility to effective and efficient health care in
community and home-settings to improve health and well-being, and contribute to morbidity and
mortality reduction. It is underpinned by the partnership between health workers, clients/patients and
members of the local community. CBHC can be provided in numerous settings in the community, by
various people including health professionals, care assistants, and non-formal caregivers such as
volunteers and family members. An important group of people in the CBHC context is the
Community’s Own Resource Persons (CORPS).

Use of CORPs like community health workers can be a cost effective way to help get services closer to
the poor people. The CORPs can be trained to do specialized tasks. Other advantages of the CORPs are
that the incentives tend to be low and they have strong community ties, resulting in retention at the
community level. CBHC using CORPs is thus an important approach in bringing services to the people
in a resource-limited setting.

9.8 SUMMARY

IN this chapter, we discussed nutrition in special needs, and we learnt that:

 A vegetarian diet is can be a healthy diet if well balanced

 Vegetarian diets are associated with reduced risks for chronic diseases
 Young children have small stomachs and eating high fibre foods may lead to them not getting adequate
calories
 The risk for protein deficiency is usually increased in vegetarian diets
 Fibre, oxalates and phytates in plant foods reduce the absorption of iron, calcium, zinc
 Calcium and Vitamin D deficiency is likely in those who do not consume dairy products
 Vitamin B12 and Zinc deficiencies are also common in vegetarians because they come from primarily
animal foods
 The most common food allergens worldwide are cow milk, eggs, fish, crustacean, peanuts, soy beans,
tree nuts and wheat
 The best management strategy for people with food allergies and food intolerance is dietary restrictions
where you avoid a diet containing the triggers.
 Excess alcohol intake reduces food intake, nutrient absorption and utilisation, and increases nutrient
loss

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 The main nutrients that alcohol affects are carbohydrates, lipids, calcium, magnesium, Zinc, Vitamins
A, D, and Bs.
 Infants born to mothers living with HIV and AIDS can be fed breast milk or breast milk substitutes
depending on the resources available and whether the mother has AIDS.
 For adults living with HIV and AIDS, a healthy diet that is adequate in terms of energy, protein, fat and
other essential nutrients is important. When facing opportunistic infections, diet should be altered
according to the symptoms.
 To avoid diarrheal diseases, food for people living with HIV and AIDS should be prepared in hygienic
conditions
 Apart from food insecurity, households in resource limited areas also face inadequate water and
sanitation, health services, schooling and job opportunities.
 Interventions in resource limited settings should be sustainable, affordable, participatory, empowering
and easy to fit into existing systems
 Food security, poverty reduction and livelihood security interventions are required in these settings;

9.9 ACTIVITIES

- Design a whole day’s menu for a vegetarian. Ensure the menu includes three main meals.

- Visit a health facility near you that is involved in the nutritional counselling of people living with HIV
and AIDS. Analyse their recommendations to mothers living with HIV and AIDS.

9.10 FURTHER READING

Donovan.U, Gibson.R.S, (1996). Dietary intakes of adolescent females consuming vegetarian, semi-
vegetarian, omnivorous diets. Journal of Adolescent health. 18:292-300

9.11 SELF-TEST: IX

This has surely been a long lecture and you should gauge how well you have understood its contents.
Each question is worth 1 mark. Answer them.

1. List 3 benefits of vegetarian diets

2. Give 2 reasons for the risk of protein
deficiency in vegetarians
3. Identify 3 anti-nutrients in vegetarian diets
and the nutrients they affect
4. Explain 4 nutrients that vegetarians are
likely to be deficient in if they do not plan
their diets well
5. Define the following:

 Food allergies
 Food idiosyncrasies

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 6. List 5 common allergenic foods
7. Give two ways of managing adverse
reactions to food
8. Outline 3 mechanisms by which alcohol
affects nutritional status
9. List 4 nutrients that excess alcohol would
compromise
10. Identify 3 breast milk substitutes for infants
born to mothers with HIV and AIDS
11. Under what circumstances would you feed
unmodified cow milk to infants born to
mothers living with HIV and AIDS
12. Explain the 3 types of modified breast
feeding for infants born to mothers living
with HIV and AIDS
13. Describe the characteristics of a resource
limited setting
14. Explain 4 criteria for nutrition interventions
in resource limited settings
15. Suggest 3 nutrition interventions you would
initiate in a resource poor setting

Now check the answers at the back page and score your performance. How did you do? If you have
scored 8 or more, good work!! You can now take a rest because we have reached the end of this
module.

10.0 GLOSSARY

Beikost- Solid food added to an infant’s diet

Body mass index- A measure of adult nutritional status, essentially

bodyweight in kilograms divided by height in metres squared (kg/m2)

Breastfeeding- the act of feeding an infant / child with milk from the human breast

Colostrum- a thick yellow fluid first secreted by the breast after birth to nourish the born baby. It
contains large amounts of immune factors, proteins, minerals and carotenoids.

Complementary feeding- Complementary feeding is the provision of foods or fluids to infants in

addition to breast-milk.

Eclampsia- Maternal convulsions in late pregnancy, a symptom of pregnancy-induced hypertension.

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Exclusive breast feeding- This is giving an infant no other food or drink (not even water), apart from
breast milk (including expressed breast milk), except for vitamins, mineral supplements or medicines in
the form of syrups or drops.

Food idiosyncrasies - adverse reactions to food or food ingredients that occur through unknown
mechanisms.

Foremilk- milk secreted at the beginning of a breastfeeding session

Growth monitoring- is measuring the weights and/or heights of individual children periodically (e.g.,
monthly) to see if they are growing adequately.

Growth promotion- is motivating caretakers, families, communities, and health workers to practice
behaviours that support adequate growth (height and weight gain) in young children.

Hindmilk- milk secreted at the end of a breastfeeding session

Intrauterine growth retardation- Birthweight below a given low percentile limit for gestational age (e.g.,
birthweight less than 10th percentile for gestational age); typically reflects inadequate supply of
nutrients and oxygen to the foetus.

Lactation- Production of milk by the mammary glands

Low birth weight- Weighing less than 2,500 grams at birth.

Metabolic food disorders- an adverse reaction to food due to genetically determined metabolic
deficiencies that either affects the ability to metabolize a specific food substance or increase the
sensitivity to the trigger chemical in the food e.g. lactose intolerance

Ovo-lacto-pollovegetarian- a vegetarian who eats milk, eggs and poultry in their diets

Ovo-lactovegetarians- vegetarians who eat only milk and eggs from animals

Pesco-vegetarian- a vegetarian who eats fish but no other food of animal origin.

Phytates- Phytic acid combined with minerals. These constitute 1-2% of the weight of whole grain
cereals, nuts, seeds and legumes, and impair mineral absorption from these foods.

Pica- a condition during pregnancy where some women crave non-food items such as ice, clay, dirt,
cigarette ashes, or starch

Prelacteal- The potentially harmful practice of delaying breastfeeding, an

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 such foods as milk, honey, or sugar water.
Primagravidae- Women who are in their first pregnancy.
Stunting- The anthropometric index 'height-for-age' reflects linear grow
postnatally, with deficits indicating longterm, cumulative effects of ina
and/or health.
Teratogenic- Causing abnormal foetal development, such as birth defects.

Transitional foods- these are complementary foods specifically designed to meet the particular
nutritional and physiological needs of the infant

True food allergies- an abnormal immunological response to a food or food component, mostly a
naturally occurring protein e.g celiac disease

Under-nutrition- A condition in which the body contains lower than nor

more nutrients.

Underweight- The anthropometric index 'weight-for-age' represents body

is a composite of stunting and wasting.

Vegan – a vegetarian who does not eat all animal products including honey.

Vegetarian- a person living on a diet of grains, pulses, nuts, seeds, veg

with or without the use of dairy products and eggs

Weaning- introducing transitional foods to an infant

11.0 ANSWERS TO SELF-TEST QUESTIONS

SELF-TEST: I

113. Chronic under-nutrition resulting from poor foetal

growth and growth deficits in 0-2 years, together
with under-nutrition in childhood and adolescence,
have a cumulative negative impact. A foetus that
has suffered intrauterine growth retardation
(IUGR) is born malnourished and has a higher risk
of dying within the first year after birth. Survivors
are more likely to have deficits in growth and
development, carry on the malnutrition throughout
life, and likely to be ill, compared to their well
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 nourished peers. If their diet does not improve,
they are likely to enter and stay in childhood
stunted and underweight. A child who is stunted at
five years of age is likely to remain stunted
throughout life. A stunted girl child is likely to
become a stunted adolescent and later a stunted
adult. Apart from direct effects on her health and
productivity, adult stunting and underweight
increase the chance that her children will be born
with low birth weight. If she gets pregnant as an
adolescent, it increases the chance of both her and
her babies being malnourished. A stunted boy child
is likely to be shorter in height, and have reduced
cognitive and physical abilities in adolescence and
adulthood thus becoming less economically
productive. This cycle repeats itself from one
generation to the next.
114. From the pyramid, the recommendations are that,
everyday, we should:

a. Take adequate amounts of fluids- 8 glasses

of water
b. Ensure half the grains consumed are whole
e.g. oatmeal, whole-wheat flour, whole
maize meal, brown rice, and whole-wheat
bread (6 servings).
c. Choose a variety of vegetables, including
dark green and orange coloured ones,
legumes (peas and beans), starchy
vegetables, and other vegetables (3
servings).
d. Focus on fruits, preferably fresh, although
canned, frozen, or dried also counts. The
fruit may be whole, chopped or pureed (2
servings).
e. Get calcium-rich foods. Milk and milk
products contain calcium and vitamin D,
both important ingredients in building and
maintaining bone tissue (3 servings).
f. Take lean or low fat meats and poultry.
Vary your protein by taking fish, nuts,
seeds, peas, and beans (2 servings).
g. Limit fats, sugars, and salt (sodium). Make
most of your fat sources from fish, nuts,

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 and vegetable oils. Limit solid fats like
butter, margarine, shortening, and foods
that contain these.
h. Include nutrient supplements when
necessary
115. The foetal stage, infants, children aged 5 years and
below, adolescent girls, pregnant and lactating
women are the most vulnerable to malnutrition
116. A malnourished person has limited opportunities in
life due to reduced potential. He is likely to be
shorter in height, and have reduced cognitive and
physical abilities thus becoming less economically
productive. In addition, they are likely to start a
family with an also malnourished peer. This makes
it hard to rise out of poverty and hunger. Their
children will grow in this limiting environment and
are thus also at risk for malnutrition, and the cycle
repeats itself from one generation to the next.
117. Conception (-9) to 23 months and Adolescence

SELF-TEST: II

118. Vitamin A deficiency, Iron deficiency and Iodine

deficiency disorders
119. Pre-pregnancy weight impacts on birth weight,
morbidity and mortality of mother and child. It
also influences fat stores for lactation.
Contraception, recent pregnancies and eating
disorders affect nutrient stores by depleting them
thus affecting what is available for the foetus.
120. Fibre, Magnesium, Selenium, Zinc , Vitamin B6,
Vitamin E, Fats and Protein
121. Folic acid, iron, iodine, Calcium
122. Consequences of maternal folic acid deficiency

 Impaired cell division

 Megaloblastic anemia resulting from abnormal cell replication due to impaired DNA synthesis
 Babies with neural tube defects such as anencephaly and spina bifida
 Low birth weight babies

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 Consequences of iron deficiency

 Anemia (low blood haemoglobin concentration)

 Maternal deaths (anemic women are more likely to die from blood loss during delivery, post partum
hemorrhage is the leading cause of maternal death in developing countries)
 Reduced transfer of iron to the foetus, increasing the infant’s risk of iron depletion and anemia in early
infancy
 Low birth weight
 Neonatal mortality
 Reduced physical capacity (the blood needs iron to carry oxygen to the brain and muscles, and the
muscles need iron for normal functioning)
 Reduced productivity
 Reduced learning capacity (anemic children score lower on intellectual tests than non-anemic children)

Consequence of iodine deficiency in pre-pregnancy period

 Impaired thyroid function resulting from severe iodine deficiency

 Goiter / enlargement of the thyroid
 Endemic cretinism (extreme form of brain damage and physical impairment)
 Mental retardation

SELF-TEST: III

139. Vitamin A deficiency, Iron deficiency, Iodine deficiency disorders, Energy deficiency and hypertension
140. Health weight gain is important because the weight not just the weight of the baby but also constituents
of pregnancy- increased fluid volume, larger breasts and uterus, amniotic fluid, and placenta. In order to
produce a healthy baby, the body requires extra fluids-extra water, blood, and amniotic fluid.
Inadequate weight gain increases the risk of delivering a baby of low birth weight. This may cause
problems with the baby's development and growth. Too much weight gain increases the risk of having a
high-birth weight baby and of getting diabetes while pregnant (gestational diabetes). This may lead to
prolonged labour and higher risk of illness for the mother
141. Essential Fatty Acids: important for the baby's normal retinal and brain development.

Calories: so as to ensure adequate weight gain throughout the pregnancy. Calories are required for
normal growth and birth weight, and for fat stores to be used during lactation.

Complex Carbohydrates: A pregnant woman's calories should come from all three energy sources
(Macro-nutrients) - proteins, fats, and complex carbohydrates. A carbohydrate restricted diet during
pregnancy puts the foetus at risk. Without carbohydrates, the body will burn proteins and fat for fuel

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 leading to inadequate protein and/ or ketones that can be destructive to foetal brain cells and the
delicate acid-base balance of the foetal system.

Protein: Adequate protein is vital since they are the building blocks of all materials in the growing
foetus (brain cells, hair, nails and other tissues). It is also needed for the build up of the mother’s
muscles, uterus, breasts and blood supply.

Zinc: Inadequate levels during pregnancy can cause prolonged labour and low birth weight babies with
health problems. The dietary intake for zinc should be 11-12 milligrams per day.

Calcium and Vitamin D: Adequate Calcium and vitamin D important for both mother and baby during
pregnancy. The two nutrients work together to build strong bones and teeth for the baby. They also help
to keep the mother’s bones and teeth strong throughout pregnancy, preventing maternal bone loss.

Iron: Pregnant women need more iron than usual because their body is manufacturing more blood -
blood volume increases by 60% in pregnancy. Iron supplies oxygen and nutrients to the foetus, supports
placental function, manufactures red blood cells, and acts as insurance against blood loss during
delivery.

Folate/folic acid: helps to decrease the risk of neural tube defects that affect a baby's spine and brain,
such as spina bifida.

Iodine: for the synthesis of thyroid hormones that in turn are required for the regulation of cell
metabolism throughout the life cycle. Thyroid hormones ensure normal growth, especially of the brain,
which occurs from foetal life to the end of the third post-natal year.

4. Alcohol may impact on the neural development of the foetus and can result in foetal alcohol syndrome
which is characterised by slow infant growth, distorted facial features, a small head and mental
retardation. Smoking tobacco is attributed to intra-uterine growth retardation resulting in low birth
weight.
5. Low birth weight babies have an increased susceptibility to infection, immature kidneys, difficulty
regulating temperatures, and problems with protein and carbohydrate metabolism. Other consequences
include increased risk for stunting, poor neuro-developmental outcomes, work capacity, chronic
disease, and mortality and morbidity.

SELF-TEST: IV

6. Breastfeeding is the act of feeding an infant / child

with milk from the human breastwhile lactation is
the production of milk by the mammary glands.
Foremilk is milk secreted at the beginning of a

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 breastfeeding session while hindmilk is milk
secreted at the end of a breastfeeding session.
7. Oestrogen from the ovary stimulates breast
development. Milk flow is initiated after the infant
begins to suckle the breast. The vigorous suckling
stimulates the anterior and posterior pituitary
glands. The anterior pituitary gland produces the
hormone ‘prolactin’ which stimulates milk
production in response to emptying of the breast at
a feeding. The posterior pituitary glands releases
the hormone ‘oxytocin’ which stimulate the release
of milk (let down reflex) from the breast in
response to suckling by the infant by causing
contraction of smooth muscles that line the alveoli
and milk ducts.
8. Calories: Despite the fact that dietary intake has
little impact on the milk production of a woman, a
breastfeeding woman should consume at least 1500
calories per day to avoid excessive weight loss,
which could decrease the breast milk quantity and
quality.

Protein: Very low protein intakes results in a reduction in the quantity rather than quality of milk. A
daily intake of 15 grams for the first 6 months followed by 12 grams per day there after is
recommended.

Calcium: Pregnancy and breastfeeding cause a temporary decrease in bone mass which is usually
regained after a woman stops breastfeeding.

Vitamin D: Calcium absorption depends on having an adequate level of vitamin D. Both breastfeeding
and non-breastfeeding women require at least 5 micrograms per day of vitamin D when sunlight is
inadequate; dependent on the season and geographic position.

Iron: Women who are not anemic after delivery and who breastfeed exclusively do not usually have a
menstrual period for the first four to six months. Thus, there is little iron lost in menstrual blood. An
iron supplement is not usually needed during this time except for women who are anemic or lost a lot
of blood after delivery usually require an iron supplement.

Folacin: Folacin deficiency is common in pregnancy and thus many women enter lactation with little
reserves. Supplementation may thus be necessary.

Riboflavin: Riboflavin is used in milk production and thus a woman should increase her intake by
0.5mgs.

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 Vitamin B6: This is especially important for women who are long term users of oral contraceptives,
since their sources are usually depleted.

Vitamin A: An intake of 6000 IU is adequate for the average lactating woman. However, A vitamin A
supplementation of high-dosage (200,000IU) should be given soon after delivery but no later than 8
weeks post-partum to protect lactating women in vitamin A deficiency endemic areas.

Fluid intake: The average woman who exclusively breastfeeds produces about 750 to 800 ml of breast
milk per day. It is adequate for a woman to drink when she is thirsty and to watch for early signs that
she is not getting enough fluids - dark colored urine, infrequent urination, dry mouth.

4. Fish: Some fish have high levels of methyl mercury, a type of mercury. High levels of mercury in the
blood can be harmful to an infant or child's developing nervous system. Tobacco: Infants of parents
who smoke have an increased risk of a number of conditions, including pneumonia, asthma, ear
infections, bronchitis, and sudden infant death syndrome (SIDS), among others.
5. Because maternal intake and stores of these nutrients have little effect on human milk concentrations
and infant status. Milk concentrations are not reduced when the mother is deficient, thus she is
vulnerable to further depletion during lactation.

SELF-TEST: V

1. Protein-energy malnutrition, Vitamin A deficiency, Iron deficiency and Iodine deficiency disorders
2. Exclusive breast feeding- This is giving an infant no other food or drink (not even water), apart from
breast milk (including expressed breast milk), except for vitamins, mineral supplements or medicines in
the form of syrups or drops. Complementary feeding- Complementary feeding is the provision of foods
or fluids to infants in addition to breast-milk. Transitional foods- these are complementary foods
specifically designed to meet the particular nutritional and physiological needs of the
infant. Colostrum- a thick yellow fluid first secreted by the breast after birth to nourish the born baby. It
contains large amounts of immune factors, proteins, minerals and carotenoids.
3. Appropriate complementary feeding is: Timely (6 months of age onwards), adequate in energy, protein,
and micronutrients, safe, and properly fed – foods are given consistent with a child’s signals of appetite
and satiety (responsive / active feeding), and that meal frequency (2-3 meals per day for infants aged 6-
8 months; 3-4 meals per day for infants aged 9-11 months and children 12-24 months and additional
nutritious snacks may be offered 1-2 times a day, as desired) and feeding method are appropriate.
4. -Complementary foods can displace breast-milk, leading to reduced production of breast-milk and thus
the risk of insufficient energy and nutrient intake

-The infant is exposed to potentially contaminated foods thus increasing the risk of diarrhoeal disease
and consequently malnutrition

-The risks of diarrhoeal disease and food allergies are increased because of intestinal immaturity,
increasing the risk of malnutrition

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 -Mothers become fertile earlier, because decreased suckling reduces the period during which ovulation
is suppressed.

Compared to cow’s milk, human milk has a

higher percentage of unsaturated fatty acids
and a higher concentration of essential fatty
acids. The long-chain polyunsaturated fatty
acids (LCPUFAs) in breast-milk are better
absorbed than those in cow milk which are
important for normal neurodevelopment
and visual cortical function. Human milk is
whey-predominant with all the essential
amino acids, whereas cow’s milk is casein-
predominant. Human milk has relatively
low concentration of iron but it is highly
bio-available. It is rich in the vitamins A
and B9.

SELF-TEST: VI

1. Break fast make a child more alert in school and better able to learn and to perform sports or other
physical activities. Benefits of regular physical activity are strong bones, good muscle tone,
psychological well-being and reduced risk of developing chronic diseases. The achievement of peak
bone mass and density during childhood and adolescence is important in reducing the risk of
osteoporosis later in life.
2. Calories: Calories are important to provide the needed energy for growth, physical activities and
mental work at school. Boys generally need more calories than girls. Protein: Protein is important for
growth and maintenance of all tissues.

Calcium, Vitamin D and Phosphorus: Adequate intake of these nutrients is essential for development of
strong and dense bones, and strong teeth. Calcium is important in the achievement of peak bone mass
and density, which begins in childhood.

Essential Fatty Acids: Essential fatty acids (linoleic acid and linolenic acid) are very important for the
child’s normal immunity, and joint and brain health. Iron: Iron is important for blood formation,

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 transport of oxygen and carbon dioxide and immunity. In childhood, it is especially needed for
synthesis of new tissues and production of haemoglobin as blood volume increases. Children with low
iron levels are often found with impaired intellectual function.

Iodine: Iodine is required for the synthesis of thyroid hormones that in turn are required for the
regulation of cell metabolism throughout the life cycle. Thyroid hormones regulate growth and
development and are required for the metabolism of energy. Worth mentioning is that iodine deficiency
can induce brain damage and irreversible mental retardation. School age children benefit from optimal
energy metabolism and factors that promote growth and development- iodine is one such factor.

3. Common nutrition disorders in adolescence are: Vitamin A deficiency and Iron deficiency. Other
disorders not common but are significant enough to mention are: Obesity, Eating disorders and chronic
energy malnutrition
4. Pregnancy in adolescence- When an adolescent becomes pregnant, she needs enough nutrients to
support both her baby and her own continued growth and physical development. If her nutritional needs
are not met, her baby may be born with low birth weight or other health problems. There is also an
increase in medical complications and risks of maternal mortality. For the best outcome, pregnant
teenagers need to seek pre-natal care and nutrition advice early in their pregnancy. Parental guidance is
required to avoid early pregnancies since they have far more implications than just nutrition.

Use of oral contraceptives- The use of oral contraceptives is common among girls to avoid pregnancies.
They usually have negative nutritional effects for instance; they reduce serum folate levels which in
turn reduce zinc levels. This then lowers immunity, sexual development and skeletal and muscle growth
and development. Long use of contraceptives also reduces pyridoxine levels in breast milk in the future.
On the flip side, they improve iron levels due to reduced menstrual flow, increase serum copper levels,
calcium absorption and conversion of carotene to vitamin A.

Alcohol, tobacco and recreational drugs- Alcohol impacts negatively on food intake and affects the
absorption of nutrients like zinc and folacin. Hard drugs like cocaine are known to reduce appetite
leading to weight loss. Marijuana is said to increase hunger but its users are known to weigh less than
non-users. Smokeless tobacco is known to increase blood pressure, blood sugar and chances of oral
cancer. It also reduces potassium levels in the body, and intake of fruits and vegetables. Interventions
should be developed to provide positive guidance so that adolescents do not engage in intake of these
substances.

5. Iron: The increase in lean body mass (LBM), composed mainly of muscle, is more important in
adolescent boys than in girls. Menstruation in girls contributes to elevated iron.

Calcium and Vitamin D: About 45% of adult skeletal mass is formed during adolescence, although its
growth continues past the adolescent period. The achievement of peak bone mass and density during
childhood and adolescence plays an important role in reducing the risk of osteoporosis later in life.
Girls should be keener on these nutrients as they are more at risk for osteoporosis than boys later in life.

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 Calories: Adolescents need additional calories to provide energy for their rapid growth and activity.
Boys ages 11 to 18 need between 2,500 and 2,800 calories each day. Adolescent girls need
approximately 2,200 calories each day.

Protein: Protein is important for growth and maintenance of tissues and muscle. Adolescents need
between 45 and 60 grams of protein each day. In adolescence growth occurs in the breasts, hips,
muscles, blood and most tissues. Boys are more muscular. Thiamine, Riboflavin and Niacin: These
nutrients play a major role in energy metabolism and thus with the increased energy intake in
adolescence, their intake should also be increased.

Folate and Vitamin B12: These are essential for DNA and RNA synthesis and are needed in higher
amounts when tissue synthesis is occurring rapidly. Rapid growth in adolescence thus necessitates their
increased need.

Zinc: Zinc is needed for growth and sexual maturation or puberty. Lack of adequate zinc usually results
in hypogonadism and growth retardation in both males and females.

SELF-TEST: VII

1. Early adulthood- covers the age range 20-40yrs. It is the period when one is at their peak of physical
health, fitness (on average at about age 30) and cognitive abilities. In the 20’s, one may still gain height,
muscle and fat, and the brain is still increasing in size and weight. There is increased weight gain from
ages 20-50 years- body fat doubles for males, 50% increase for females. One’s senses are optimal,
biological function and physical performance reach their peak from 20-35 years of age, waning after
35. Strength peaks around 25 years of age, plateaus through 35 or 40 years of age, and then declines.
Flexibility also decreases with age throughout adulthood. However, there are large individual
differences and a fit 40-year-old may out-do a sedentary 20-year-old. During this stage, the body
continues to undergo significant hormonal changes. Men’s beards grow a little thicker and their voices
become slightly deeper and richer. Women reach their peak fertility in their early 20s. They also gain a
little weight and finish their full breast development. Basal metabolism declines in both sexes compared
to puberty.

Middle adulthood- from approximately ages 40-60 yrs. There is a decline in physical skills and strength
and flexibility in both genders wane. Vision, light sensitivity, hearing, kidney function and cardiac
output also decrease. Men usually gain weight in the abdominal region, while women gain weight in
the hips and thighs. Women also experience hormonal changes during this period that result in the loss
of the ability to reproduce, a process called menopause. After 55, there is decrease in height or increase
in weight, approximately 2 inches lost for men and 1 inch for women. Important to note is the
decreasing bone density (for women, loss is twice as fast). This group has fewer accidents but more
chronic diseases, heart disease being most common, then cancer. There is the “catching up” effect of
lifestyle where one used to get away with many unhealthy habits but no longer can. One now requires
active attempt to improve and should create an exercise routine to avoid weight gain.

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2. - An adult woman- to perform at their places of work, college, and other responsibilities like parenting,
adequate energy is required. Women are generally vulnerable to deficiencies of Vitamin A, folic acid
and Vitamin B12 that are especially important for women of reproductive age as these vitamin
deficiencies impact on pregnancy outcomes. Calcium, Vitamin D and phosphorus are essential for
achievement of peak bone mass and density, which continues into early adulthood. Women are more
affected by osteoporosis in old age than men. Iron is also important for women of reproductive age for
the health and survival of both the woman herself and her babies. The same goes for folic acid and
iodine. Zinc and selenium both play a role in fertility, immunity and scavenging of free radicals.

 A man working as a farm labourer- More calories are needed to provide energy for manual labour.
Protein to maintain muscle is also important. Thiamine, Riboflavin and Niacin play a major role in
energy metabolism and thus, depending on one’s energy needs (weight and physical activity level),
their intake should also be considered.

3.

NUTRIENT RECOMMENDATIONS
Protein Minimum of 10% of total energy intake
Maximum of 40% of total energy intake when BMI is
Total fat
Maximum of 35% of total energy intake when overwe
Cholesterol Maximum 300 mg/day, intake is not compulsory
Saturated fatty acid Maximum 10% of total energy intake, intake is not co
Carbohydrates Minimum of 40% of total energy intake
Dietary Fibre 15-22g/100calories of 28-40g/day

4. Zinc, selenium and Vitamins A, C and E

5. Adulthood gives way to more chronic diseases, heart disease being most common, followed by cancer.
In middle adult-hood, there is the “catching up” effect of lifestyle where one used to get away with
many unhealthy habits but no longer can. One now requires active attempt to improve and should create
an exercise routine to avoid weight gain.

SELF-TEST: VIII

6. Osteoporosis, Obesity, Anaemia, Cardio-vascular

diseases, Lowered immunity, Impaired glucose

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 tolerance, Malnutrition – drug and / or food
induced
7. Smell and taste changes- Loss of appetite,
decreased number of taste buds and smaller
olfactory bulbs makes food usually seems less
palatable.

Sight and peripheral vision usually declines and may lead to less activity by leading to fear or inability
to cook or read food prices and nutrition labels. This affects grocery shopping, food preparation and
eating.

Loss of or reduced hearing may lead to less eating out or not asking questions of the waiter or grocery
store clerk due to embarrassment.

The sensations of thirst and hunger can also diminish as the body's signals for lack of fluids get weaker
with age.

3. Caloric needs are reduced due to reduced because the elderly have more body fat, less lean muscle and
reduced activity. Calcium helps maintain bone strength by slowing the rate of calcium loss from bones,
which begins after the age of 30 and accelerates in later years, especially in women. For iron, anaemia
is a common problem in the elderly due to poor dietary intake, absorption, use of some drugs and blood
loss.
4. -Having their dentures adjusted and they can also chop, steam, stew, grind or grate hard or tough foods
to make them easier to chew.

-Osteoporosis can be counteracted by a diet high in calcium and weight-bearing exercises. Treatments
like oestrogen replacement, calcium and Vitamin D supplements are also available.

- To cope with solitary living and eating, one can try new things to add mealtime sparkle or get together
to cook and eat with friends and relatives.

- Variety can be created in colour, texture and flavour. Flavour can be varied using spices, new foods
and herbs/ ingredients. One can also eat frequent smaller meals.

- To cope with financial constraints, planning is important- preparing a shopping list. One can also take
advantage of low prices by picking foods in season and looking out for discounts. Buying items in bulk
also ensures savings.

- When the sensations of hunger and thirst diminish, one can use outside reference points and signals to
guide him or her (time of day, people they live with, etc.). Eating and drinking should therefore be
scheduled.

- Digestive issues like constipation, diarrhoea, bloating and feelings of fullness can be dealt with by
balanced nutrition, eating fibre-rich foods and plenty of fluids.

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 -Enriched foods and supplements together with a healthy diet helps meet daily nutrient requirements.

-Regular exercise has several benefits. It prevents muscle deterioration, promotes mental equilibrium,
and helps prevent chronic diseases.

5. Fluids and fibre

SELF-TEST: IX

6. -Reduction in risks of suffering from heart disease

as a result of lower blood cholesterol amongst
vegetarians.

-Reduction of the risk of suffering certain cancers. Meat eating has been identified as a possible dietary
risk factor in prostate, pancreas, colorectal and lung cancers.

-Lower blood pressure.

-Less chance of becoming overweight or obese since they gain a lower proportion of their energy from
fat.

-Vegetarians are also less likely to suffer from gallstones, appendicitis and food poisoning.

2. The risk for protein deficiency is usually increased in vegetarian diets because:

-Some of the protein that would normally be used for growth is diverted to be used as energy in high
fibre low energy diets

-Plant foods mostly have incomplete protein (do not have all the essential amino acids) and if not well
mixed, can lead to growth deficits.

3. Oxalic acid: Interfere in the absorption of iron and calcium by forming insoluble complexes with
them.

Phytic acid: Interfere in the absorption of iron zinc, copper and calcium by forming insoluble
complexes with them.

Poly-phenols: Interfere in the absorption of iron and the macronutrients- protein, lipids and starch. An
example is tannins.

Dietary fibre: High amounts interfere in the absorption of iron and other micronutrients by binding
them, decreasing intestinal transit time and making them physically unreachable due to bulk.

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 Goitrogens: These prevent the intestinal reabsorption of thyroxine, resulting in hypertrophy of the
thyroid gland

Protease inhibitors: They inhibit the action of digestive enzymes thus decreasing protein digestion

Lectins: E.g in foods like soy bean interfere in the absorption of carbohydrates.

4. Calories and Fat: A diet with lots of fresh fruits, vegetables, and whole grains is high in fibre and
may lead to them not getting adequate calories.

Protein: The risk for protein deficiency is usually increased in vegetarian diets because some of the
protein that would normally be used for growth is diverted to be used as energy in high fibre low
energy diets and also plant foods mostly have incomplete protein (do not have all the essential amino
acids) and if not well mixed, can lead to growth deficits.

Iron: Fibre, oxalates and phytates in plant foods reduce the bio-availability of non-haem iron.
Vegetarians’ iron sources are mainly non-haem iron.

Calcium: This is of particular concern for those who do not take dairy products and also because plant
foods have compounds that inhibit calcium absorption.

Zinc: Zinc is mainly obtained from animal foods and may thus be inadequate in a vegetarian diet.

Vitamin D: This is especially important for those who do not consume dairy products and do not get
frequent exposure to the sun.

Vitamin B12: It is found primarily in meat, eggs and dairy produce, which are of animal origin.

5. A food allergy is an abnormal immunological response to a food or food component, mostly a

naturally occurring protein e.g celiac disease, while a food idiosyncrasies are adverse reactions to food
or food ingredients that occur through unknown mechanisms.

6. Cow milk, Eggs, Fish, Crustacea (crab, shrimp, lobster), peanuts , soy beans, Tree nuts (almonds,
walnuts, hazelnuts) andWheat
7. -Dietary restrictions where you avoid a diet containing the triggers.

-Breastfeeding for extended periods of time

-Use of pro-biotic during lactations reduces likelihood of allergenic sensitisation and lactose
intolerance.

-Use of hypoallergenic infant formula may prevent the development of the allergies

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 -Processing of foods to extract or remove the allergenic ingredient. E.g removal of gluten in wheat
products for celiac disease.

-Pharmacologics likes antihistamines are used to manage the symptoms if one is exposed.

8. - Displaces food in the diet thus affecting nutrient intake

-Affects food intake by depressing the appetite

-Affects the gastrointestinal tract thus affecting nutrient absorption and digestion

-Affects the liver thus interfering in the transport, use and storage of some nutrients

-Increases the excretion of nutrients in urine and bile

-Increases nutrient requirements due to increase in metabolic rate

-Money spent on alcohol may also reduce money allocated for food

9. Carbohydrates, lipids, calcium, magnesium, Zinc, Vitamins A, D, and Bs

10. - Commercial infant formula

- Home-prepared formula

- Modified animal milks

- Dried milk powder and evaporated milk

- Unmodified cow’s milk

11. Unmodified cow’s milk could be considered as an option by HIV-positive women when commercial
infant formula is not available or is too expensive for the family to buy and prepare; the supply of
cow’s milk is reliable and the family can afford it for at least six months; the family lacks the resources;
time and fuel to modify cow’s milk to make home-prepared formula and micronutrient supplementation
is possible.
12. -Expressed and heat-treated breast milk- Heat treatment of expressed breast milk from an HIV-positive
mother kills the virus in the breast milk but reduces the levels of the anti-infective factors.

-Breast-milk banks- In some areas, milk is available from breast-milk banks. Breast-milk banks are
generally used as a source of breast milk for a short time, not an option for meeting the nutritional
needs of infants for a long period.

-Wet-nursing- In some areas there is a tradition of wet-nursing where a relative breastfeeds an infant.
There is a risk of HIV transmission to the infant through breastfeeding if the wet-nurse is HIV-infected.

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 There is also a potential risk of transmission of HIV from the infant to the wet nurse, especially if she
has cracked nipples.

13. Food insecurity, crowded housing, inappropriate child and maternal care, inadequate water and
sanitation, health services, schooling and income generating activities.
14. Interventions in resource limited settings should be sustainable, affordable, participatory, empowering,
easy to fit into existing systems and reduce inequalities
15. Food security, supplementation, public health interventions, nutrition education and communication,
poverty reduction and livelihood security interventions, research and nutrition therapy.

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