Nutrition and the

Lifecycle
An overview

Note: These slides bring together core knowledge, key

data and references. While all may not be presented
in the lecture, they form part of the resources for the
week
Nutrition and Pregnancy
 Stages of Pregnancy & their nutritional
demands

Implantation 0-2 wks

Organogenesis/Embryogenesis 2-8 wks
Fetal stage remaining 30-32
wks

Implantation Fertilized ovum embedded in uterus wall

embryo
Fertilized ovum
placenta

Nutrients provided directly to ovum from secretions from the uterus

Placenta
Nutrient Transfer in the placenta
 Placenta
Plays an active role in reproduction
- production of reproductive hormones
- transfer of nutrients, oxygen, waste products

NB: Fetal & maternal blood never mix

Nutrient transfer
Free fatty acids, cholesterol, fat soluble vitamins (simple
diffusion)
Carbohydrates, mainly glucose (facilitated diffusion)
Amino acids, water soluble vitamins (active transport)

Efficiency of nutrient transfer important for fetal well-being

Organogenesis Organ formation and cell differentiation

ectoderm (brain, nervous sys., hair, skin)

embryo mesoderm (muscle, bone, cardio & renal systems)
endoderm (digestive, respiratory & glandular organs)

Nutrition provided from secretions from the uterus & via growing placenta

“Critical periods” for development of tissues/organs

Evidence animal studies

riboflavin - skeletal formation
B12 & folate - CNS

Little info on ‘critical periods’ in humans

except – ample folate needed between 2-4 weeks for neural tube
development
Fetal stage Growth & expansion of newly formed organs

Nutrition provided via fully grown placenta

Stage 1 hyperplasia (cell replication ) - folate & vitamin B12

Stage 2 hyperplasia & hypertrophy (cells grow in size) – amino acids & vit. B6
Stage 3 hypertrophy continues

little known re. consequences of specific nutrient deficiencies

inadequate nutrition  intrauterine growth retardation (IuGR) & low birth weight

IuGR & LBW - higher rates of morbidity & mortality

- impaired immunity & infectious diseases
- higher risk of growth failure
- higher risk of poor cognitive development
- higher risk of chronic disease in later life (Barker Hypothesis)
 Average curve of fetal growth
4 At approx. 8 weeks: 6-10g

3.5 At approx. 24 weeks: 0.5kg

3 At term (38-40 weeks): ~ 3.5kg

2.5
Kilograms

1.5

0.5

0
8 12 16 20 24 28 32 36 40

Weeks of pregnancy
Effects of under-nutrition during stages
of pregnancy – what is the evidence?

• Not ethical to do randomised controlled

trials

• Barker’s Hypothesis & studies

[More in week 4]

• Dutch Hunger Famine

1939-1945 - Second world war
Holland was occupied by Nazis
Food rationing in place

Then……in winter of 1944……………………….

- Nazis stopped all transport in/out Western Holland
- Dutch transport workers mounted a strike
- Extremely cold winter – ice block all canal transport
- Largest cities worst affect

So no food could get in……result = in severe

malnutrition……

Dutch Hunger Famine

lasted for 6 months from November 1944-May 1945
Susser & Stein, 1994
 Retrospective observational study
Met criteria for a natural experiment
- famine was short

- sharp & measurable change from norm

- food intake known i.e. records of food rations

- exposed populations could be accounted for

national statistics, local authority registers,
military records, hospital records

Data for births from 1944-1946 (3 years) were assembled in birth cohorts

A1 not affected by famine

B1, B2 – babies born during the famine
D1, D2 – babies conceived during the famine
Susser & Stein, 1994
Effect of exposure to Dutch Hunger Famine on Maternal Weight
(immediately after birth)

Susser & Stein, 1994

Effect of exposure to Dutch Hunger Famine
on Infant Birth Weight

Susser & Stein, 1994

Effect of exposure to Dutch Hunger Famine on Stillbirths

Susser & Stein, 1994

 Summary of Findings

Exposure to severe malnutrition in early pregnancy:

 still births
 deaths during first week of life
 CNS defects such as NTDs like spina bifida
 schizoid and antisocial behaviour at 19 years in men
 schizophrenia at 50 years two-fold in men & women

Exposure to severe malnutrition in late pregnancy:

 maternal weight gain
 infant birth weight
 infant length & head circumference
 placental weight Susser & Stein, 1994
 Major Maternal Changes During Pregnancy
• Large increase in weight (average 12.5kg)
– Baby (~3.5 kg), body fat stores (~ 4kg), placenta & amniotic fluid (~ 1.5kg),
growth of uterus and breasts (~ 1kg), increased blood & fluid (~ 1-2kg)

• Changes in gastrointestinal function

– progesterone  relaxes muscles in GI tract  slows movement food through
gut   absorption of nutrient

– constipation, heartburn

• Metabolic adjustments
– 20%  BMR by term, change in fuels used for energy, modest insulin resistant
state develops

• Many other changes including:

– blood volume and composition,  in cardiac output, changes in blood pressure,
respiration, renal function, wide range in hormonal and other changes
Maternal Weight Gain & birth weight

Abrams et al. 2000 AJCN, 71 (Supplement 1):1233S-41S

 Pre-Pregnancy Weight: Infant Morbidity in
Underweight and Normal Weight Controls

Infant Morbidity Low Pre-pregnancy Normal

Weight
Weight Controls
(% of births) (% of births)

Low birth weight 15.3 7.6

Prematurity 23.0 14.0
Low Apgar score 19.0 12.0
 Obesity & Pregnancy
In US > 30% of pregnant women are obese
In UK 20% of pregnant women are obese

Early pregnancy
Study of 56,857 women showed 1.4 fold risk of congenital abnormalities
born to obese women
2-fold increase in NTDs in obese women compared with normal weight

Late pregnancy
 risk of having large for gestational age (LGA) baby
 risk impaired maternal glucose tolerance, gestational diabetes,
high lipids

King, 2006
 Pre-Pregnancy Weight: Overweight and risk of
complications

90
In cid en ce o f co m p licat io n s

80
Hypertension
70
Pre-eclampsia
60
Gestional diabetes
50
Urinary tract infection
40
Pre-term Labour
30
Caesarean section
20
Hospitalisation
10
0
18-24.9 25-29.9 30-34.9 >35
Pre- p reg n an cy b o d y m ass in d ex

Galtier-Dereure et al (1995). Int J Obes; 19: 443-448.

Weight Gain Chart
Recommended Weight Gain Ranges for Women

Weight for Height Category Kg

Low (BMI <19.8) 12.5-18
Normal (BMI 19.8-26) 11.5-16
High (BMI >26-29) 7-11.5

* young adolescents should strive for weight gains at upper end of the recommended ranges
*Short women should strive for gains at the lower end of range
*Obese women should gain at least 7kg

Institute of Medicine, 1990

After genetics - maternal weight at conception and her
weight gain during pregnancy the most important
predictors of infant birth weight.
 Nutrient Reference Increment for
nutrient intake pregnancy
for women 19 to
50 years
DRVs Energy (kcal) 1940 (EAR) + 200 1
Protein (g) 45.0 +6
for Calcium (mg) 700 *
Iron (mg) 14.8 *
Pregnancy Phosphorus (mg) 550 *
Magnesium (mg) 270 *
Sodium (mg) 1600 *
Potassium (mg) 3500 *
Chloride (mg) 2500 *
Zinc (mg) 7 *
Copper (mg) 1.2 *
Selenium (g) 60 *
Iodine (g) 140 *
Notes: Vitamin A (g) 600 + 100
* No increment Thiamin (mg) 0.8 + 0.1 1
Riboflavin (mg) 1.1 + 0.3
1 for last trimester only Niacin (mg) 13 *
2+ 400g/d pre-conceptionally Vitamin B6 (mg) 1.2 *
Vitamin B12 (g) 1.5 *
and until 12th week, or +
Folic acid (g) 200 + 100 2
5mg/d for women who have
Vitamin C (mg) 40 + 10
had a previous pregnancy
Vitamin D (g) - 10
affected by NTD.
 DRVs for Pregnancy

For most nutrients - no DRV increment

This does not imply that there is no increase in metabolic

demand

but that the extra demand is met by:

– normal adaptation
– increased absorption
– stores of the nutrient
 Pregnancy & Energy Intake
COMA recommendation + 200kcal to EAR in last trimester only
Calculated as
40,000kcals - change in tissue mass (fetus, placenta, uterus etc.)
30,000kcals -  BMR
70,000kcals = total energy cost of pregnancy

- 70,000kcal energy cost - seldom matched by food intake

- energy intake  by about 100kcal/d during last few weeks

Why? Better absorption

Less energy expenditure/physical activity
Some energy sparing adaptation?

Underweight & very active women may need more energy

Protein +6g increment throughout pregnancy

Provide protein for growth of fetal and maternal tissues
 Folic Acid & Pregnancy
Folate – natural form, unstable
sources – liver, leafy green vegetables, green beans, yeast extract

Folic acid – synthetic form, more stable, more bioavailable

Role in body:
Folate - needed for DNA synthesis, cell division and replication

Folate cofactors provide….

- single carbon groups (C) for synthesis of purines and pyridines, and thus
DNA
- methyl groups (-CH3) needed for the methylation cycle to modify structure &
funciton of proteins, lipids, DNA

Deficiency
Folate – lead to anaemia
Modest  folate status – lead to  risk of neural tube defects (NTDs)
Now proven that folic acid can significantly  risk of NTDs

MRC Vitamin Study (1991)

–RCT 33 centres 7 countries
- 1,817 pregnant women with history of NTD
- supplementation with folic acid  risk of NTD by 72% (highly significant)

But efforts to get women to take supplement have failed badly

- needed before most women know they are pregnant
- 50% pregnancies are unplanned
- compliance with taking supplements very poor

Fortification
In UK, COMA (2000) predicted fortification at 240g/100g would  NTDs by
41%
- concerns about masking B12 deficiency and have deferred decision

In US – they currently fortify flour at 140g/100g which has  NTDs by 20%

Folic acid: current UK recommendations:

Pre-conception:
To prevent recurrence of NTDs: 5mg daily until 12th wk of
pregnancy
To prevent first occurrence: 0.4 mg daily until the 12th week of
pregnancy

During pregnancy: Increasing intake by:

- 100 g/d increment - eating more foods rich in folate
- eating foods fortified with folic
acid
- taking folic acid supplements
 Vitamin A & Pregnancy
UK RNI (600 g/d) + extra 100 g/d = 700 g/d

Extra vitamin A needed for…….

• growth & maintenance of the fetus
• providing stores of vitamin A for the fetus
• maternal tissue growth

In UK - most women have intakes above those recommended

Thus, very few need vitamin A supplements

Caution - retinol is teratogenic at high doses (i.e. > 3300 g/d)

Pregnant women should not take

- vitamin A supplements (including fish oil capsules)
- liver or liver products
 Vitamin D & Pregnancy
UK recommendation - supplementary vitamin D to achieve intake of 10g/d

Extra vitamin D needed to…….

• maintain heightened calcium absorption & utilisation during pregnancy

- vitamin D status of women is maintained more by exposure to sunlight

- diets only provide 2-2.5 g/d
- very few good dietary sources

High prevalence of vitamin D deficiency

in Asian women
 Vitamin C
UK RNI (40mg) + extra 10mg/d in last trimester

Extra vitamin C needed to…….

• ensure that the mother’s vitamin C stores are maintained.
In 3rd trimester - rapidly growing fetus places moderate drain on
mother’s circulating levels and stores.

Thiamin and Riboflavin

- extra 0.1mg/d thiamin in 3rd trimester (from 0.8mg to 0.9mg/d)
- requirements for thiamin parallel energy requirements

- extra 0.3mg/d riboflavin (from 1.1mg to 1.3mg/d)

- also related to energy requirements
 Iron & Pregnancy
Iron is needed during pregnancy for…….
• increased blood volume
• growth in fetal body tissue
• growth in maternal body tissue

In UK RNI adult females = 14.8mg/d

No increment during pregnancy

Extra demand on iron should be met by….

• mother’s iron stores
• cessation of menstrual losses
• increased intestinal absorption
 Iron & Pregnancy

Maternal iron deficiency and iron deficiency anaemia  risk of

- preterm delivery
- low birth weight
- low iron status of the infant

Iron status should be checked regularly throughout pregnancy

In UK - iron supplements are not routinely recommended/prescribed

If iron stores are low or mother in high risk groups (adolescents,

successive births, low-income group) need supplements
 Iron & Pregnancy
USA, IOM (1993) recommendations
Stage
1st trimester Check iron status 30mg or 60-120mg or no
supplement
2nd trimester Check iron status 30mg or 60-120mg or no
supplement
3rd trimester Check iron status at least 30mg/d

Cogswell et al (2003)
RCT show that compared with placebo, supplementation with 30mg/d up
to 28 wks in iron-replete pregnant women……
- had no effect on incidence of iron deficiency anaemia
- sig. increased birth weight
- sig. lower incidence of low birth weight (LBW) infants
- sig. lower incidence of preterm LBW infants

Problems with iron supplements:

- not always well tolerated (nausea, diarrhoea, constipation)
- may affect the bioavailability of zinc
 Calcium & Pregnancy
COMA recommendation - no increment, RNI = 700 mg/d

Extra calcium needed for…….

• fetal requirements (baby at birth contains 25-30g Ca)

Extra demand for calcium thought to be met by….

• mother’s bone density reduced and replenished later
• increased efficiency of intestinal absorption
• urinary excretion is reduced

Higher calcium intakes needed for adolescent pregnancies as

- growth spurt may have reduced calcium stores - thus stores may be insufficient
- mother’s bone density and/or growth may be affected
- also, calcium intakes and thus stores may be insufficient

In USA: RDA increased by 400mg/d to 1200mg/d during pregnancy (all women)

 Percentage of Young Women (aged 15-18 years) with
mineral and vitamin intakes below LRNIs
Nutrient LRNI % age below
LRNI
Magnesium (mg) 190 53
Iron (mg) 8 48
Calcium (mg) 480 19
Zinc (mg) 4 10
Vitamin A (g) 250 12
Folic acid (g) 100 4
Vitamin C (mg) 10 0
National Diet and Nutrition Survey 4-18 year olds (2000)

Recent meta-analysis of 9 studies on diet in pregnant adolescents - reported poor intakes

of energy, folate, calcium, vitamin E and magnesium
(Moran, 2007; BJN; 97: 411-425)
 Nutrition
In recent years - increasing emphasis on nutrition
• prior to conception
• first trimester

Dietary advice for women:

- planning pregnancy and for first 12 weeks
- during remainder of pregnancy
 References
Chapter 6 (Pregnancy & Lactation) Nutrition & Metabolism. Gibney et al.
Nutrition Society Textbook.

King (2006) Maternal Obesity, Metabolism and Pregnancy outcomes Annu

Review Nutr 26: 271-91.

Susser & Stein (1994) Timing in Prenatal Nutrition: A reprise of the Dutch Hunger
Famine Study. Nutrition Reviews: 52, (3); 84-94.

Information on dietary advice during pregnancy

Food Standards Agency http://www.eatwell.gov.uk
British Nutrition Foundation http://www.nutrition.org.uk/
Department of Health http://www.doh.gov.uk/
Maternal Nutrition for Lactation

Dr Alison Parrett
 Physiological changes that occur
after birth in lactating mother

• Basal metabolic rate (BMR) falls

• Body fat stores used to provide energy for lactation

• Appetite increases

• Hormonal changes
The composition and amount of milk produced is
not influenced by the mother’s food intake

At least until malnutrition becomes severe

Exceptions
Fat composition
Water soluble vitamins
 Composition
• Approx 700mL
– Lactose 72.0g  2.5
– Protein 10.5g  2.0
– Fat 39.0g  4.0
• Maternal dietary fat intake influences fat
composition of breast milk
• Water soluble vitamins– influenced by dietary
intake of mother
• In general – milk nutrient levels are protected,
if necessary by depletion of mothers stores
 Changes to DRVs for lactation
•  energy requirements (450-570 kcals) based on energy required
to produce milk, energy content of milk, and allowance for fat loss
• No change in proportion of energy from, or type of fat or
carbohydrate
• Increment for protein to cover the protein content of breast milk
• For most vitamins and minerals - increments are to cover levels in
breast milk
• Vitamin C - increment to ensure maternal stores and levels in milk
are kept high

• No increment for some minerals eg. sodium intakes already high

• No increment for iron - should come from stores and ↓ losses

Breast milk
 Stages of Breastfeeding
Colostrum
0-2 days
30ml/d, high in sIgA & vitamin K,

Transitional
3-10 days
As baby  suckling   volume of milk

Mature Milk
from 10 days
Foremilk - higher in lactose and water
Hindmilk – higher in fat & energy
 Nutritional Composition of Breast milk
Energy 50% fat
40% carbohydrate
10% protein

• Proteins in breast-milk are easier to digest, less likely to cause allergy

• Oligosaccharides in breast-milk fed  babies suffer less from

constipation

• More LCPUFA & EFA  cognitive development

• Minerals more bio-available

• Less protein & minerals  lower renal solute

 Non-Nutritional Benefits of Breastfeeding
Fewer infections
especially gastrointestinal and respiratory

1. lowers exposure to bacterial pathogens in contaminated

food/water

2. contains immune-protective factors

immunoglobulin A, lactoferrin, lysosyme, bifidus factor,
macrophages, lymphocytes etc….
 Other non-nutritional benefits of breastfeeding
• Cow’s milk allergy
• Cognitive & visual development
• Chronic disease ( duration BF   risk insulin dependent diabetes)
•  likelihood of overweight & obesity
• Sudden Infant Death Syndrome
• Promotes recovery after childbirth
• Fosters maternal - infant bonding
• Reduces fertility - lactational amenorrhoea
• Reduces mother’s risk of iron deficiency
• Breast feeding > 2 years - reduce risk of breast & ovarian cancer
• Weight loss
• Economic benefits
• Environmental benefits
 Breast Feeding Rates

Only 35% of world’s population are exclusively

breast fed for 4 months

(WHO Global Data Bank on Breastfeeding, 2001)

 Infant feeding Report 2005
• There has been a steady increase in breastfeeding

• Breastfeeding was higher amongst ……

first time mothers, those in managerial and professional
occupations, those aged over 30 and those with highest educations
levels.

• Significant increase in BF from 2000 to 2005

mothers were older, more mothers were in full time
education for longer

The UNICEF (UK) Baby Friendly Initiative’s Ten Steps to

Successful Breastfeeding (1992)
Complementary Feeding …..
……is the provision of foods or fluids to infants in addition to
breast milk or breast milk substitute (WHO/Unicef, 2000)

When should complementary feeding start?

“not be given solids before 4 months, and a mixed diet should be

offered by 6 months” (Department of Health, 1994)

“WHO recommend that infants be exclusively breastfed for first 6

months”
Thus complementary feeding should start at “about 6
months”. (WHO/Unicef, 2000; Department of Health, 2001)
Physiological factors influencing nutrition during infancy

• Growth

• Eating skills & co-ordination

• Digestion and absorption

• Renal function

• Intestinal mucosal barrier is immature

Developing co-ordination skills needed to eat
 Practical Advice on Stages of Weaning
Stage 1
small amounts, single ingredient, 1-2 times per day
smooth consistency e.g. baby rice, mashed potato, soft porridge, pureed fruit/veg
breastfeeding on demand should continue - main source of fluid, energy & nutrients
Stage 2
2-3 small meals per day - well cooked pureed meats, pulses, vegetables, fruit and cereals
breastfeeding on demand should continue - main source of fluid, energy & nutrients

Stage 3
2-3 meals & small snacks - transitional foods become  important
foods with a thicker consistency & lumpier texture
learning to chew and manage small pieces of food - teeth starting to appear
 variety – veg, fruits, meat, fish, egg, cheese, finger foods (e.g. toast, cooked carrot, pear)
breastfeeding on demand should continue
Stage 4
3 main meals + 2 snacks - by 1-2 year, infant should share normal family diet.
variety of foods - chopped, mashed and minced foods, finger foods
infant gradually starts to self-feed
breastfeeding continues to be an important part of diet
(UNICEF/WHO, 2000)
* More practical advice on FSA & BNF websites
 Problems associated with ….
Early weaning
• renal solute load
• infection - increased risk of diarrhoea
• adverse reactions to foods i.e. allergy, coeliac
• obesity

Late weaning
• energy intake not sufficient - growth faltering
• low iron intake and increased risk of iron deficiency anaemia
• low vitamin D intake
• delay in development of motor and eating skills
 Digestion & Absorption
In utero
Nutrients obtained from mother’s blood via placenta in usable form
At birth
Food must be taken by mouth, digested & absorbed
Secretion of digestive enzymes not fully developed
Breast milk contains some digestive enzymes e.g. lipase
Infant able to produce lactase from birth
Able to digest & absorb nutrients in breast milk more efficiently

Gastric Capacity – small (100ml newborn infant vs. 500ml adult)

but increases during infancy ( energy dense diet)

By 6 months
Able to starch, protein and fat in non-milk diet
 Renal Function
At birth
limited renal capacity to deal with high solute load (proteins and minerals)
breast milk is low in solutes, high in fluid
formula designed not to overload with solutes

Potential renal solute load (mosmol/L)

Breast milk 93
Infant formula 135
Whole cow’s milk 308

By 4 months
renal function has matured considerably
able to conserve water and deal with varying solute concentrations

By 6-8 months
can cope with  volume of fluids and  concentration of nutrients

By 1 year
renal function reached that of adult
 Renal Function Definitions

Renal Solute Load – sum of solutes i.e sodium, chloride, potassium,

phosphorus, nitrogenous compounds resulting from the
digestion of protein ingested in excess of body needs

Potential Renal Solute Load – refers to the solutes that would have
to be excreted if none were used for the synthesis of new
tissues or lost through non renal routes.

.
 Immature mucosal barrier
At birth, intestinal muscosal barrier is immature and vulnerable to injury by
- bacteria
- protein antigens
- toxins

Breast milk contains …………………sIgA, lactoferrin, lysozyme, macrophages,

lymphoctyes, oligosaccharides, trophic factors

- stimulate development of active defence mechanisms

- prepare gastrointestinal tract for transitional foods

Foods containing potentially antigenic proteins include

soya protein, gluten, cow’s milk, egg, fish

avoided before 6 months, especially if history of food allergy

 Mother’s attitudes to infant feeding

Mother’s responses (%)

Not important Important and No response

very important

Wide variety of foods 3 95 2

Plenty to drink 1 98 1
Plenty of calories 20 76 4
Low fat intake 10 88 2
High fibre intake 15 83 2

Survey of 1000 mothers about views on feeding practices.

(Morgan et al., 1995)

 Iron deficiency and Iron deficiency anaemia
• High prevalence of iron deficiency in infants
Inner city areas: 1/6 white British children 1-2 years

1/2 Asian children

National Survey of Infants in UK

12% anaemic
28% iron deficient

(National Nutrition Survey 1.5-4.5 year olds, 1995)

 Iron deficiency and Iron deficiency anaemia
0-4 months
total body iron does not increase
small amount in breast milk, but well absorbed
low iron intake may be an advantage - pathogens require iron for
multiplication

after 4 months
iron requirement high - period of rapid growth, psychomotor development
iron stores may become exhausted if dietary iron supply is low
early introduction of cow’s milk should be avoided
thus, iron-rich diet (complementary foods) important
e.g. liver, meat, pulses, iron fortified complementary foods, follow-on milk
also - strong case for supplementation from 6 months
 Iron deficiency and Cow’s Milk

Over-dependence on milk increases risk of iron deficiency

Study:
1,003 1.5-4.5 year old children in NDNS

Results:
Hb & serum ferritin - significantly lower in 1.5-2.5 year olds
Iron status - positively related to consumption of meat & fruit
- inversely related to milk consumption

Conclusion: >400ml/d milk, children less likely to eat other foods

Also, cow’s milk is low in iron & not very bioavailable

cow’s milk in 1st year of life - related to iron loss through G.I. Bleeding

(Public Health Nutrition, 2000; 3: 433-440)

 Infant feeding recommendations
Fat
fat intake recommendations don’t apply < 2 year, but apply in full from 5 years
(Department of Health, 1994)

Cow’s Milk
whole milk should only be used as a main drink > 1 year
semi-skimmed milk is not suitable <2 years, but may be introduced gradually if
child is eating well and growing satisfactory
skimmed milk should not be given before 5 years
(Department of Health, 1994)

8-9 months olds receiving cow’s milk in UK

67% in 1985
15% in 1995
8% in 2000

Asian Infants receiving cow’s milk at 9 month

25-30% (Infant feeding Surveys, 1985-2000)
 Follow-on Formula
Compared to cow’s milk, follow-on formula provides higher content of:
• vitamin A
• vitamin C
• vitamin D
• iron
and have a lower renal solute load (Dept. Health, 1994)

Infants receiving follow-on rather than cow’s milk, receive more appropriate
amounts

• protein (less)
• iron (more)
• vitamin A (more)
• vitamin D (more)
 Vitamin Supplements
Breast fed
infants < 6 months do not need vitamin supplements
> 6 months, infants should take vitamins A, D & C drops

Formula fed
do not need extra supplements (provided consumption > 500ml/d)

Infants - should take vitamin A, D & C drops - at least up to 2 years

(Department of Health, 1994)

 Infant feeding Goals
• increase proportion of mothers exclusively breastfeeding to 6
months (WHO, 2003)

• ensure mother’s choosing not to breast feed have safe alternative

and know how to use formula appropriately.

• emphasis importance of good weaning diet

energy, fat, iron, vitamin D

• reverse decline in uptake of vitamin supplements

(Department of Health, 1994)
 References
Butte et al. (2004) Journal of the American Dietetic Association 104 (3) 442-54

Feeding and Nutrition of infants and young children. Guidelines for the WHO European Region, with
emphasis on the former Soviet countries. UNICEF/WHO (2000). European Series no. 87. Chapter 8
(Complementary feeding).

Chapter on Pregnancy & Lactation. (2003) Nutrition & Metabolism Nutrition Society Textbook Series

Department of Health (1991) Report on Health and Social Subjects no. 41. Dietary Reference Values for
Food Energy and Nutrients for the United Kingdom. Committee on Medical Aspects of Food Policy.
HMSO. London.

Infant Feeding Survey (2005) http://www.ic.nhs.uk/pubs/breastfeed2005

Infant Feeding Survey (2005) http://www.ic.nhs.uk/pubs/breastfeed2005

Practical advice on http://www.eatwell.gov.uk/agesandstages/baby/

Practical advice on British Nutrition Foundation website

Nutrition for pre-
school, school
children and
adolescents
 Lecture outline

• Pre-school children

• School children • Biology / physiology

• Factors affecting nutrition

• Adolescents

Evidence: UK National Diet and Nutrition Surveys

(NDNS )
Height as a function of age
 ICP model for growth:

• Infancy

• Childhood

• Puberty

A mathematical model breaking down linear growth

from birth to adulthood into 3 components that reflect
the different hormonal phases of the growth process.
Karlberg J. Acta Paediatr Suppl 1989; 350: 70-94
ICP Concept
 ICP model– which hormones?

• Phase 1 – infantile: Insulin, IGF1, IGF2,

maternal environment?

• Phase 2 - childhood: growth hormone (GH)

and thyroxine (T4)

• Phase 3 – puberty: GH &T4; GH is increased

by estrogen in both male and female
 Pre-school children (1-5 year olds)

• Already achieved:
- Introduction of complementary foods (weaning)
- Pincer grasp
- Can use spoon (struggle with rotation)

• Feeding ‘milestones’:
- Use of spoon (12 mo)
- Independence at mealtime (18 mo)
- Refusal / irrationality around food (24 mo)
- Social eating (3-5 yo)

- Later on: anxieties re. food

Factors influencing nutritional requirements of
pre-school children (2-5 year olds)
• Period of rapid growth / very vulnerable to
growth faltering
• Period of rapid brain development
• Small stomach
• Infections common
• Physical activity – child now walking
• Development of teeth
• Fussy eaters – neophobia
• Important time for development of healthy
eating habits
• Dependent on others for food – very
vulnerable
Biological context: young children need an
energy & nutrient dense diet
• Adult female (~60kg) • 2 year old child (15kg)
Energy requirements Energy requirements
2000 kcal/day 1100 kcal/day
33kcal/kg 73kcal/kg

 Young child has very high energy & nutrient requirements

for their size
 Need energy & nutrient dense diet ;
Difficulties – small stomach, small appetite, tend to be fussy
eaters, very vulnerable to undernutrition; obesity epidemic
& overnutrition
 Neophobia – ‘fear of new foods’

• Evolutionary protective response

• Initial neophobic rejection can be transformed
into a preference with repeated exposure
• Less well developed in babies
• toddlers may require 5-10
exposures for acceptance

Birch et al. (1998) Appetite; 30: 283-295

 Maternal reports of neophobia & pickiness
• Italian mother – child (2-6y) pairs
• Likert scale questionnaires
• Neophobia and pickiness correlated
• Maternal / child neophobia correlated
(ro=0.223, p=0.012)
• Maternal / child pickiness correlated
(ro=0.311, p=0.001)
• Overweight & obese children more
neophobic (p=0.03) and picky (p =0.03) than
normal-weight children
Finistrella et al. (2012) Cross-Sectional Exploration of Maternal Reports of Food Neophobia and Pickiness in
Preschooler-Mother Dyads, Journal of the American College of Nutrition, 31:3, 152-159, DOI:
10.1080/07315724.2012.10720022
 Adiposity rebound

• Possible critical period for ‘programming’ of

later obesity risk

• Early adiposity rebound

– Under the age of 6
– Adiposity rebound is getting earlier
Reilly Proc Nutr Soc 2008
 Adiposity rebound

Patterns of Growth Associated With the Timing of Adiposity Rebound

Sheila M. Williams and Ailsa Goulding - Obesity (2009) 17 2, 335–341.
 Dietary recommendations for 1-5 year olds
• healthy, varied diet
• but low-fat, high fibre dietary guideline does not apply
• include protein & iron-rich foods – red meat, liver, poultry, fish, pulses
• fruit and vegetables - eat 5 child-sized portions
• milk an important source of calcium & protein
• vitamin drops - A, D, C: not widely adopted in UK

Also healthy eating patterns

- regular small meals inc. breakfast, healthy snacks & drinks
physical activity should not be ignored
(assumption they are ‘supercharged dynamos’)
fussy eaters

Caroline Walker Trust

 What young children do all day
Objectively measured (Reilly et al Lancet 2004)
 What do pre-school children in the UK
eat?
National Diet and Nutrition Survey of 1.5-4.5 year olds (1997)
NDNS Rolling survey (years 2008-2011)

Methods (7-day weighed intakes, anthropometry, blood samples)

•Special diets – 1% vegetarian, 0% vegans in the sample

Energy intakes compared with EARs for 1.5-3 year olds
Energy intake EAR % EAR
(kcal) (kcal)
All
1.5-2.5 1,045 1,190/1,130 88/92
2.5-3.5 1,160 1,280/1,230 90/94
Boys
3.5-4.5 1,273 1,490 85
Girls
3.5-4.5 1,183 1,370 86
National Diet and Nutrition Survey of 1.5-4.5 year olds (1995)

No gender discrimination in this age group in NDNS rolling

survey – average energy intake of 1.5-3 yo is 1127 kcal
 Proportions of energy from protein, fat and
carbohydrate and NSP intakes in preschool
children
% energy 1995 2008/2011
Protein 13.0 15.3
Fat 35.9 34
Saturated Fat 16.2 14.8
Starch, intrinsic & milk sugars 32.4 39.2
NME sugars 18.7 11.4

NSP (g/d) 6.1 8.1

National Diet and Nutrition Survey of 1.5-4.5 year olds (1995)

and 1.5-3 years old (2008/2011)
 Dietary intakes of vitamins in 1.5-3 year olds
%RNI %<LRNI*

Vitamin A (g/d) 136 9

Thiamin (mg/d) 189 0
Riboflavin (mg/d) 240 1
Niacin (mg/d) 242 0
Vitamin B6 (mg/d) 205 0
Folate (g/d) 222 0
Vitamin C (mg/d) 224 1
Vitamin D (g/d) 27** n/a

** Vitamin D intake alone not good indicator of vitamin D status (better to look at 25 hydroxy vitamin D
levels in blood)
National Diet and Nutrition Survey of 1.5-3 year olds (2008/11)
 Dietary intakes of minerals in 1.5-3 year olds
%RNI %<LRNI*

Iron (mg/d) 92 8
Calcium (mg/d) 221 1
Selenium (mg/d) 163 1
Magnesium (mg/d) 181 1
Potassium (mg/d) 226 1
Zinc (mg/d) 103 6
Copper (mg/d) 141
Iodine (mg/d) 208 1

* Proportion of children reporting intake less than LRNI

National Diet and Nutrition Survey of 1.5-3 year olds (2008/11)

NDNS: Diet and nutritional status of under 4’s in UK
• Energy and nutrients
Energy intakes lower than EARS, but children taller and heavier than
before- reduced energy requirement ?
Low in zinc and iron (consistent with 1995 survey)
1995 survey shows: 20% iron deficiency (serum ferritin <10g/L), 8%
anaemia (haemoglobin <11g/dl) and low vitamin A, C and D status (some
groups)
Social inequalities in diet present early (e.g. ALSPAC)
Intakes of B vitamins, Ca, P, Mg, K well above RNIs
• Foods
Low intakes of meat, fish, fruits & vegetables
High in NME sugars
Milk important contributor of nutrients
21% children taking supplements
* Scottish children had poorest diets
 Schemes for Preschool Children

• Vitamin drops - A, D, C free to children in

families on income support (uptake very
low)
• Children attending nursery (England)
receive 1/3 pint per day (Nursery Milk
Scheme by English Dept Health)
• Children < 5 year eligible to receive free
pint of milk (Welfare Food Scheme)
•Variety of local schemes around free fruit
provision e.g. Glasgow City Council
 Other factors - preschool

• Risk of chocking
• Colours and preservatives which may
affect behaviour
 Summary 1-5y olds from NDNS

• A number of problem nutrients identified (poor

intake; poor status) - some deficiency present
– E.g. iron, zinc

• Largely due to inadequate nutrient intake

• Energy intake adequate or even high

– So the problem is ‘micro-nutrient density’ of diet
Factors influencing nutritional requirements
of schoolchildren & adolescents
ICP Concept
 Growth & development

5-10 yrs – ‘slow but steady’ period growth & development

highest obesity incidence (Hughes et al 2010)

Adolescence
growth spurt -starts at around 10 yrs in girls, around 12 yrs in
boys

changes in body composition

Before adolescence – both boys & girls 15% body fat
During adolescence – boys  10%; girls  20%
 Growth Spurt influences DRVs for adolescent
boys & girls
Males Females Difference
• EAR energy (kcal)
11-14 yrs 2,220 1,845 375
15-18 yrs 2,755 2,110 645
Protein (g/d)
11-14 yrs 42.1 41.2 0.9
15-18 yrs 55.2 45.0 5.2
Calcium (mg/d)
11-14 yrs 1,000 800 200
15-18 yrs 1,000 800 200
Phosphorus (mg/d)
11-14 yrs 775 625 150
15-18 yrs 775 625 150
Zinc (mg/d)
11-14 yrs 9.0 9.0 no difference
15-18 yrs 9.5 7.0 2.5
 General Principles of Healthy Eating Apply
from 5 yrs

• Base your meals on starchy foods

• Eat lots of fruit and vegetables

• Eat more fish

• Cut down on saturated fat and sugar

• Try to eat less salt – no more than 6g a day

• Get active and try to be a healthy weight

• Drink plenty of water; Don’t skip breakfast

Food, choices & control – school children &
adolescents
Study in 9 yo schoolchildren
- 90% reported control over breakfast content
- 66% reported control over snack consumption
- 33% reported control over amount of food consumed
(Robinson, Journal of Human Nutrition & Dietetics, 2000)

Special diets
2% of boys / 7% of girls 11-14 yo on vegetarian / vegan diet
1% of boys / 10% of girls 15-18 yo on vegetarian / vegan diet
(Gregory & Low, NDNS report, 2000)

Influence of family, peers, media

 Development of Eating Disorders

•Anorexia nervosa, bulimia nervosa, binge

eating disorders – psychological illnesses
characterised by disturbance in eating.
Prevalence: 1-2% young people, 90%
female

•Dieting among teenagers – most

important predictor of new eating
disorders
 Iron Requirements are high during
childhood and adolescence

Accelerated growth   blood volume & muscle

mass   iron requirements
Onset menstrual bleeding (teenage girls)   iron
requirements
RNI = 11.8mg/d teenage boys
vs.
14.8mg/d in girls
 Iron deficiency(ID) and ID anaemia common in
school children & adolescents

Iron deficiency Anaemia

Boys 4-6 yrs 17% 8%
7-10yrs 16% 2%
11-14yrs 18% 9%
15-18yrs 5% 1%
Girls 4-6 yrs 13% 10%
7-10yrs 3% 4%
11-14yrs 11% 3%
15-18yrs 22% 9%

(National Diet and Nutrition Survey; NDNS, 2000)

Why is having Iron deficiency (ID) or ID anaemia
a problem?

• Tiredness

• Loss of appetite
• Poor weight gain/growth
• Greater number of
infections
• Affects performance and
learning at school
 NDNS: problem nutrients in childhood &
adolescence

• Social inequalities
• Vitamin D established early e.g.
ALSPAC Study
• Iron
• Calcium
• NDNS shows some
• Energy (obesity)
poor intake; some
deficiency

Fruit and veg intake is poor: average 3 portion /day with

only 11 / 8 % meeting the 5-a-day target
Oily fish intake is poor – not meeting the 1 portion/wk
target
 Large proportion of English children &
adolescents physically inactive

•46% boys
•69% girls
•spend <1 hr participating in activities of
moderate intensity (>3 times REE). English Health
Surveys
•Chief Medical Officer England (2004)
 About 25% of peak bone mass (PBM) acquired during adolescence

PBM 25-30% greater in boys than girls

 nutrient requirements for bone synthesis higher for boys

 requirements for – calcium, vitamin D

- Ca absorption  30%
- weight bearing exercise important

Consequences of poor Ca intake

- skeletal growth may be affected
- adult height may be reduced
- reduced peak bone density  increased risk of osteoporosis

Adult peak bone mass – 80% genetics, 20% calcium intake & wb exercise
 Calcium and bone density – evidence for
supplementation
Impact of dairy products and dietary alcium on bone-mineral content
in children: Results of a meta-analysis
Bone, Volume 43, Issue 2, August 2008, Pages 312-321
Michael Huncharek, Joshua Muscat, Bruce Kupelnick

• No impact on TBMC for all RCT pooled together

• Pooling the three reports utilizing low intake subjects yielded a

statistically significant summary mean BMC of 49 g.

•Pooling two RCTs using calcium/dairy supplement plus vitamin D was

also associated with an increase in lumbar spine BMC of ~35 g
 Calcium and bone density – evidence for
supplementation
Effects of calcium supplementation on bone density in healthy
children: meta-analysis of randomised controlled trials
Winzenberg, Tania; Shaw, Kelly; Fryer, Jayne; et al.
BMJ Volume: 333 Issue: 7572 Pages: 775-778F

• Small effect on TBMC (standardised mean difference 0.14, 95% confidence

interval 0.01 to 0.27) and upper limb BMC (0.14, 0.04 to 0.24). This effect
persisted after the end of supplementation only at the upper limb (0.14, 0.01
to 0.28).
• There was no evidence that sex, baseline calcium intake, pubertal stage,
ethnicity, or level of physical activity modified the effect.
• Calcium supplementation in healthy children has no effect on bone density
at the hip or lumbar spine
• Supplementation has a small effect at the upper limb, but the resultant
increase in bone density is unlikely to result in a clinically important decrease
in risk of fracture
Iodine status in UK teenage girls
• Dietary sources
• Urinary iodine as marker of iodine status
• Multicenter cohort study identified moderate iodine deficiency
• Potential issue for future pregnancies
• Risk populations – vegans, dairy avoiders

(Vanderpump et al. 2011; Lancet)

What do children & adolescents in the UK
eat?
National Diet and Nutrition Survey of 4-18 year olds (2000 and
Rolling Survey in 2008/2011)

Methods (4 or 7-day weighed intakes, anthropometry, blood samples)

Average energy intakes as a % EAR by age and sex
Energy intake EAR (MJ) % EAR
Males 2000 2008/11
4-6 1,527 1,715 89
1591
7-10 1,785 1,970 91
11-14 1,981 2,220 89
2007
15-18 2,294 2,755 83
Females
4-6 1,403 1,545 91
1519
7-10 1,606 1,740 92
11-14 1,895 1,845 89
1637
15-18 1,630 2,110 77

•National Diet and Nutrition Survey (NDNS) of 4-18 year olds (2000)
Macro nutrient contribution to total energy intake by
gender and age
% Energy from
Protein CHO Fat NMES
Males
4-10 12.6 / 14.4 52 / 51.8 35.4 / 33.7 17.2 / 14.4
10-18 13.4 / 14.9 50.4 / 50.4 35.3 / 33.7 16.2 / 15.8
Females
4-10 12.9 / 13.3 51.2 / 50.3 35.9 / 35.6 17 / 14.3
10-18 14.3 / 14.2 51.3 / 50.6 34.4 / 34.3 15.6 / 15.1

•National Diet and Nutrition Survey of 4-18 year olds

(2000) and 2008/2011
Average intakes of vitamins by 4-18 year olds

•National Diet and Nutrition Survey of 4-18 year olds (2008/11)

 Average intakes of minerals 4-18 year olds.

•National Diet and Nutrition Survey of 4-18 year olds (2008/2011)

National Diet and Nutrition Survey of children aged 4-
18 years.
Summary of findings

Energy intakes below EARs for all groups

Mineral intakes of are inadequate, especially for the teens
Iron deficiency major problem
Some groups had low vitamin D status
Intakes of NMES high (intakes of soft drinks very high) – but
slight decrease over 10 years
Low intakes of fruit and vegetables
20% took vitamin supplements
Supplements in childhood & adolescence

• Case can be made for calcium and others ?

• Deficiency relatively common e.g. >20% of
children and adolescents in UK
• Are ‘correct’ nutrients being supplemented
?; by the right people ?; the ‘worried well’ ?
• Recent emphasis on essential fatty acid
supplements and cognition; ?misplaced
Children and alcohol intake
Other factors influencing children and
adolescent diet & nutrition
 Barriers for healthy eating

• Qualitative studies / focus groups

• Main themes relate to convenience, availability,
meal times & setting, TV on/off, food retail
landscape, cost, school rules, parental influences,
impact of sport / exercise, impact on appearance
(self)

Swingburn 1999, Preventive Medicine

McKinley 2005, Eur J of Clinical Nutrition
 Over nutrition (obesity) vs.
undernutrition (deficiency) ?
• Both appear to be • Conflict in tackling both
increasing in UK and USA- problems ?
national surveys • Apparent conflict (e.g. UK
• Undernutrition not going National Audit Office
away Surveys of teachers)
• Public & health hinders progress
professional perceptions
incorrect (e.g. Parry et al 2008 J
Ambul Care Manage 31: 253-268)
 Food provision in schools

“Hungry for success” strategy in Scotland

 Food provision in schools

“Hungry for success” strategy in Scotland

 School meals blog

http://neverseconds.blogspot.co.uk/2012_05_01_archive.html
Nutrition & Elderly
Definition of Elderly

elderly > 65 years

young elderly 65-74 years

older elderly > 75 years

(Department of Health, 1992)

Proportion of world’s population > 65 years is
increasing

16 15%
14

12 11%
10 9.4%
8.5%
8
6

4
2
0
1 2 3 4
1980 1990 1999 2000

Abrahms (2000) EJCN, 54 Suppl 3, S2-14

 Proportion of elderly increasing in UK and
Europe

2007 - 20% UK population > 65 years

Estimated that by 2030……

30% Europeans will be > 60 years

Number of people > 80 years will increase by 50%

(British Nutrition Foundation , 2007)

 Proportion of population > 65 years
1980 2005
Europe France 12.4 14.8
Germany 14.5 18.9
Greece 13.1 16.9
Hungary 12.5 15.0
Italy 13.0 16.9
Poland 9.4 12.3
Sweden 16.9 17.2
UK 15.1 15.3

North Canada 10.4 12.5

America USA 12.0 13.1

Australia 10.1 11.4

Japan 10.0 16.5
Less Brazil 4.3 5.8
Developed China 5.1 7.4
CountriesIndia 4.3 5.8
Kenya 2.1 2.1
Mexico 3.5 4.6

(Wahlqvist et al. 2003)

 Life Expectancy is increasing

Year Life Expectancy

Developing countries 1950 46y
1990 64y (men & women)
2000 72y

Developed countries
Men Women
1900 37-48y 38-59y
1950 59-64y 71-72y
1990 67-73y 75-82y

Abrahms (2000) EJCN, 54 Suppl 3, S2-14

Ageing/Senescence
Biological and physiological changes that begin around 30 years
and are degenerative in their effect

- influenced by genetic & environmental factors

Chronological vs. biological age

Theories of ageing
• Programmed ageing
• Error theory
• Free radical theory

(Wahlqvist et al. 2003)

 Factors that may influence longevity
Animal Studies
Energy restriction
Rate of growth
Physical activity

Human Studies
Body weight
Healthy lifestyle practices
Food variety
Physical activity
Social activity
 Nutrition & Elderly

Why is nutrition important ?

• Improve quality of life
• Delay onset of chronic disease
• Reduce impact of chronic disease on nutritional status
• Some evidence that nutrition can influence life span
Physiological changes of ageing that influence
nutritional status/requirements

• Changes in body composition

• Declining bone density
decreasing synthesis of vitamin D
• Gastrointestinal Changes
• Decline in vision
• Decline in cognitive function
• Changes in cardiovascular system
• Decline in immune function
 Body composition changes with age

 muscle (lean) tissue

 body fat

subcutaneous fat redistributed from limbs to trunk

 bone mass
 Decline in Muscle Mass with Age

 lean tissue (muscle)  body fat

▪ esp. after 80 yrs,  after menopause

Sarcopenia – involuntary loss of lean tissue

Why?
• Hormones change with age
 insulin, growth hormone, androgens ( lean mass)
 prolactin ( fat mass)
•  sedentary lifestyle

Consequences:  strength, mobility, balance

 frailty, risk of falling
 glucose tolerance
 energy requirements
Decline in Muscle Mass with Age

(Fontera et al. 1991 J App Physiol 71: 644)

 Exercise can reverse decline in Muscle Mass
with Age

100 male nursing home residents in 90s enrolled in resistance training

program
 9% mid thigh muscle area
 174% muscle strength of leg
(Fiatarone et al. 1994)
Ageing   muscle mass
 Energy requirements
 Bone mass declines with age
Bone mass reaches peak around 30 years and declines thereafter
- rate of decline increases after menopause
- increased risk of fracture below threshold of bone density

Osteoporosis (porous bone) -  risk of fracture

25% of females > 60y affected

Osteoporosis incidence
People living longer
Reduction in weight bearing activities
(Harvey & Cooper, 2004)
 Bone mass declines with age

Peak bone mass

Menopause

Bone mass

Threshold below
which risk of
fracture increases

20 30 40 50 60

Age (years)
 Calcium and vitamin D are both essential to protecting
against Osteoporosis

25-hydroxyvitamin D levels decline with age…..

- reduced dietary intake
- reduced sun exposure
- reduces synthesis with age

In UK, 37% institutionalised elderly adults have low vitamin D status

In UK and USA, 30-40% of those who have a hip fracture are vitamin
D deficient
(BNF Task Force Report on Healthy Ageing, 2009)
 Evidence relating to supplementation with calcium &
vitamin D is conflicting

Epidemiological studies - vitamin D & calcium intake important in

maintaining bone mass & ↓ risk of fracture

Finnish study (persons > 85 years) – group randomly assigned to

receive an annual vitamin D injection had significantly fewer fractures
over a 5 year period

RCT (3,270 women, 84 years) – vitamin D (20g) & calcium (1200mg/d) group had
43% fewer hip fractures and 32% fewer non-vertebral fractures over an 18-month
period

Large, RCT, supplementing with 400 IU vitamin D found no benefit.

(studies discussed in Harvey & Cooper, 2004)

 Gastrointestinal changes
• Dental problems   ability to chew food

• Xerostomia
 flow of saliva, drying of mouth,
influences taste, difficulty swallowing

•  risk of constipation (4-8 times more common)

Intestine loses strength & elasticity with age   motility
Effects of diet, medications & lack of exercise

• Decline in the secretary ability of the digestive glands

• Gastric atrophy/atrophic gastritis (inflammation of stomach)

 HCL secretion, (achlorhydria)
 mucosal cells esp. parietal cells ( intrinsic factor)

 absorption of B-vitamins, iron & calcium
Reduction in serum B12 concentrations
 Folate & B12
Vitamin B12
maintains sheath that surrounds & protects nerve fibres
deficiency  pernicious anaemia
due to mal-absorption/lack of intrinsic factor
can cause permanent nerve damage & paralysis

Folate
deficiency  megaloblastic anaemic (immature red blood cells)
B12 needed to convert folate into active form
folate or B12 deficiency can cause megaloblastic anaemic

Either B12 or folate  treat magalobloastic anaemia

Thus, folate supplementation can mask B12 deficiency

Framingham study (elderly cohort)

Studied blood folate levels before & after manditory fortification
Folic acid fortification - doubled blood folate levels
-  90% low folate blood concentrations
 Cognitive function – role of fatty acids
Cognitive impairment & dementia – frequent disorders in elderly

Solfrizzi et al. (2005) – review on fatty acids & cognitive decline & dementia
17 cross-sectional & longitudinal study, no RCT had been carried out

Saturated fat intake – negative effects on cognitive function

n-6, n-3 PUFA, MUFA, weekly fish consumption – appear to be protective against
cognitive decline & alzheimer’s disease

Possible mechanisms
High MUFA intake – marker of diet high in antioxidants
LCPUFAs – maintaining structural integrity of neuronal membranes, aiding
transmission of signals between neurons
(Solfrizzi et al. 2005 Exp Gerontology 40: 257-70
 Cognitive function – B vitamins
Cross-sectional study on 1,789 elderly latinos (>60y) had red blood cell folate
measured & tests for cognitive function & dementia carried out. Low concentrations
of folate & B12 – associated with poor cognitive function & dementia in elderly
(Ramos et al. 2005; AJCN 82: 1346)

Leiden 85-Plus Study, Netherlands

599 elderly subjects, serum vitamin B12, folate conc. & standard cognitive tests
Lower serum folate associated with greater cognitive impairment
(Mooigarrt et al. 2005; AJCN 82: 866)
Glasgow; RCT (185 patients >65y); given supplement (folic acid, B12, B6,
riboflavin); not associated with significant benefit in cognitive function in short or
medium term)
(Scott et al. 2005 AJCN 82: 1320)
Netherlands, double blind, RCT, 195 elderly subjects received vitamin B12 and/or folate for 24
weeks; no effect on cognitive function reported
(Eussen et al. 2006; AJCN; 84: 361)
 Vision – Role for antioxidants?
Cataract – clouding of the lens due to chemical changes that occur with age
Macular degeneration – breakdown of part of the retina

Brown et al. (1999) study of US males, ↑ serum carotenoids associated  cataract

But mixed results from RCTs

22,071 males (Physican’s Health Study) – supplemented with B-carotene for 12
years; no effect on whole; reduced risk in smokers (RR 0.74; 95% CI 0.57-0.95)
(Christen et al. 2003 Arch Opthalmol)
39,876 females (Women’s Health Study) – supplemented with B-carotene for 2 year.
No protective effect (Christen et al. 2004 Opthal Epidemiol)

17 cataract patients, 2 year, vision improved with lutein group; no effect of vitamin E
(Olmedilla et al. 2003 Nutrition)
 Drug-Nutrient Interactions - Elderly Implications
In USA 12% population elderly
35% prescription drugs consumed by elderly
increasing number of medications with increasing age

• Many drugs likely to interfere with absorption of nutrients

• Some drugs interfere with appetite

taste and smell

• Some drugs cause drying of mouth/difficulty swallowing

constipation

Supplement use
44% consumers between ages 66-83 y
24% consumers between ages 43-65 y

(Abrahms, 2000)
 Factors influencing food selection in elderly

Psychologic Physiologic Socioeconomic

Loneliness Loss of appetite Level of income
Bereavement Loss of taste Cooking facilities
Social isolation Dental problems Level of education
Food Aversion Prescribed diets Distance to shops
Symbolism of food Chronic disease Availability of transport
Mental awareness Food intolerance
Feelings of self-worth State of health
Food faddism Physical disability
Nutrition knowledge Degree of physical exercise
Dissatisfaction with Vision problems
living situation
 DRVs for Elderly
In general, same as for adults except

Energy kcal
men 19-59y 2,550
60-64y 2,380
65-74y 2,330
75y+ 2,100

Vitamins
Vitamin D +10g supplement
Minerals
Iron (women 8.7mg/d vs 14.8mg/d)

Department of Health (1991)

 The problem of declining energy
requirements

 energy requirement   food intake

But requirements for other nutrients are maintained or

increased

Can you get adequate amounts of nutrients while

eating less food?
 Dietary intake of Elderly in UK
Elderly National Diet & Nutrition Survey
Nationally representative sample > 65 years
1275 Free-living population
412 Individuals living in institutions

Weighed diet record for 4 days

Questionnaire on general health, cognitive ability or memory, bowel
movements
Physical measurement
Blood & urine samples

Reference: Finch S, Doyle W, Lowe C et al. National Diet & Nutrition Survey: people
aged 65 years and older , vol 1: Report of the Diet and Nutrition Survey, The
Stationary Office, 1998
Proportion of subject over 65 with vitamin intake
below LRNI (%)
Free Living Living in Institutions
Men Women Men Women
Vitamin A 5 4 1 1
Thiamin <1 <1 <1 <1
Riboflavin* 5 10 3 3
Niacin <1 <1 <1 <1
Vitamin B6* 2 3 1 2
Vitamin B12 <1 1 0 0
Folate* 1 6 4 5
Vitamin C* 2 2 1 0
Vitamin D 97% intake below RNI 99% intake below RNI
* increases with age (Finch at al. 1998)
 Proportion of subject over 65 with mineral
intakes below LRNI (%)

Free Living Living in Institutions

Men Women Men Women
Iron* 1 6 5 6
Calcium 5 9 1 <1
Magnesium* 21 23 39 22
Sodium 0 0 0 0
Potassium* 17 39 28 42
Zinc* 8 5 13 4
Iodine 2 6 1 1

* increases with age (Finch at al. 1998)

 Low Biochemical Parameters
Free living Institutional

Thiamin 10-15% 10-15%

Riboflavin 40% 40%
Folate 15% 40%

Vitamin C 15% 40%

25-OH 8% 37%

Haemoglobin 11% men 52% men

9% women 39% women

(Finch at al. 1998)

 Dietary intakes of Elderly
SENECA follow-up study – European Survey on Nutrition and
Elderly

• 24% men, 47% women had inadequate intake of one of more nutrients
• iron and riboflavin - highest prevalence of inadequate intakes
• prevalence of inadequate intakes decreased with increasing energy intakes
men women
Iron 1300kcal 75% 66%
1900kcal 17% 30%

Riboflavin 1300kcal 55% 68%

1900kcal 30% 43%

No single energy intake value ensured no inadequate intakes

Age and Ageing; 1999; 28: 469-474.

 Recommendations of Elderly Report (1992)
Physical activity is important to ensure adequate energy intake

Maintain healthy weight

Reduce intakes offat especially saturated fats

simple sugars ‘empty calories’

Increase intakes starchy foods

NSP (except raw bran)
vitamin C
Fortification of vitamins A and D in fats should continue
Vitamin D -sunlight/supplements
Eat more fresh vegetables, fresh fruit and whole grain cereals
Regular consumption oily fish
Reduce salt intake
Department of Health (1992)
 Summary

• Elderly - fastest growing section of the population

• Ageing brings gradual decline in normal physiological

function

• Energy needs usually decrease with age but nutrients

needs remain same - nutrient density of diet
important

• Vitamins & minerals most likely to be lacking in diet

• Numerous social, physiological and economic factors

influence food and nutrient intake in older person – all
these  risk of nutritional problems.
 Directed Reading

Walqvist et al. (2003).Chapter on Growth & Ageing. Nutrition & Metabolism

Nutrition Society Textbook Series (eds. Gibney M.J. & McDonald I.A. and Roche,
H. M.), Blackwell Publishing.

Harvey & Cooper (2004) Chapter on Osteoporosis & Hip Fracture. Public Health
Nutrition; Nutrition Society Textbook Series (eds. Gibney M.J. & McDonald I.A.
and Roche, H. M.), Blackwell Publishing.