6.

1: Proper Nutrition Throughout

Development
From conception to death, nutrition has a lasting impact on our growth and development.
This module will explore the role of nutrition in pregnancy, lactation, infancy, childhood,
adolescence, and adulthood.

Pregnancy
A healthy baby is the desired outcome of every expectant parent. Wise choices related to
social, health, environmental, and nutritional factors during pregnancy can all affect the
health of the baby. In fact, creating a healthy environment begins prior to conception. An
adequate intake of vitamins and minerals several months prior to conception, as well as
throughout the pregnancy, is strongly recommended for those trying to conceive. A healthy
body weight, properly controlling existing health conditions, and the avoidance
of teratogens (compounds that can increase the risk of a birth defect) will also improve the
odds of a healthy pregnancy for both mom and the baby. Examples of teratogens include
smoking, medications, recreational drugs, tobacco and alcohol.

Note: Although one might expect a low mortality rate for both mom and baby in the United
States, that is not the case. Despite the availability of health care, either through private
companies or programs available for low income and needy moms, the rate of infant
mortality is among the highest in the world. Teen moms are especially at high risk as they are
more likely to not seek proper care during their pregnancy.

Pregnancy can be defined by several key developmental stages:

• Fertilization (Day 0): An egg and sperm unite and produce a zygote.
• Blastogenic stage (Day 1 to 14): A period of rapid cell division
o Day 14: An embryo is formed.
• Embryonic stage (Week 2 to 8): The organ system develops.
o Week 5: The heart begins to beat.
o Week 8: The embryo is now known as a fetus.
• End of first trimester: Most organs are formed, and the fetus can move.
• Fetal Stage (Week 9 to 40): Period of continual growth and development

Beginning at conception, an egg and sperm unite and produce a zygote. Over the next 14
days, cell division occurs rapidly and is referred to as the blastogenic stage of the pregnancy.
At its conclusion on day 14, an embryo is formed. Weeks 2 through 8 are called the
embryonic stage as the organ system develops. At week 5 of the pregnancy, the heart is
beating, and by week 8 the embryo is known as a fetus. By the end of the first trimester, most
organs are formed, and the fetus can move. Weeks 9 through the remainder of the pregnancy
are called the fetal stage and are periods of growth. During the pregnancy, the placenta
provides oxygen and nutrients from the mother’s blood to the fetus and also allows for the
transfer of waste from the fetus and into the mother’s system for excretion.
As outlined above, the length of a normal pregnancy is approximately 40 weeks and is
divided into 3 trimesters.

First trimester: This is an extremely important time for development and growth of the
fetus. Unfortunately, many women do not realize they are pregnant until the second month of
the pregnancy. By this point cell division and crucial periods of growth have already
occurred. During crucial periods of development exposure to toxins and inadequate nutrient
intake can have an adverse effect on the fetus. It is important that moms eliminate harmful
substances from their diets and lifestyles prior to conception to improve the chances of
having a healthy baby. In order to ensure adequate nutrients for the fetal development, the
quality of the mother’s diet is more important than the quantity.

Second trimester: During this period, development of the hands, feet, arms, and legs occurs,
and the fetus begins to resemble a baby. The expectant mother is also experiencing
physiological changes to her body in order to support the pregnancy and prepare for birth.

Third trimester: Pregnancy is in a critical period of growth as the fetus will double in length
and will increase weight to approximately 7 to 9 pounds.

The benchmark period for an infant to be born is after 37 weeks of gestation. After this time,
which is the period of intrauterine growth, a baby weighing greater than 5.5 pounds has a
more positive outcome, less chance of medical issues, and an overall better quality of life.
However, not all babies are born under ideal conditions. An infant born prior to 37 weeks is
referred to as preterm. Preterm infants are likely to have increased medical conditions and
delayed growth in their early months of life.

Based on their weight at the time of birth, an infant may be also classified as:

Low birth weight (LBW): An infant weighing less than 5.5 pounds, regardless of their
gestational age.

Small for gestational age (SGA): An infant small in size, measured relative to its gestational
stage.

Thus, an infant born at 35 weeks and weighing 5 pounds would be considered LBW but not
SGA, as 5 pounds at 35 weeks is within the normal range.

Nutrition During Pregnancy

Although many factors affect the outcome, an adequate diet, accurate education, and proper
prenatal care can increase the chances of a successful pregnancy. During pregnancy one
should consider the following:

1. Calories: Quality is more important than quantity during the first trimester. Mom should
make certain she is eating all the vitamins and minerals needed for a healthy pregnancy.
Foods that are high in sugar and fats should be limited while the focus should be on nutrient-
dense foods. The idea of eating for two is a misconception—the calorie needs are not
doubled, but rather, the need for certain nutrients increase by 50% during pregnancy. Further,
the calorie needs during the second and third trimester only increases by approximately 20%.
2. Adequate weight gain: A healthy weight gain of 25-35 pounds during pregnancy is a
good predictor of a healthy pregnancy. The following are standard weight gains
recommended for a healthy pregnancy: 1-4 pounds during the first trimester and then
approximately 1 pound per week during the remainder of the pregnancy. The chance of
complications during pregnancy and delivery increases when a pregnant mom is
overweight/obese or if the baby is larger than normal. The weight gain for pregnant and
overweight/obese moms is less than 25 pounds. Likewise, underweight or pregnant teens
require a higher weight gain to support the pregnancy,

The latest recommendations of weight gain for a full-term pregnancy from the Institute of
Medicine:

• Underweight: 28 to 40 pounds
• Normal: 25 to 35 pounds
• Overweight: 15 to 25 pounds
• Obese: 11 to 20 pounds

3. Increased protein and carbohydrate needs: Most women eat adequate amounts of
protein in their normal diet. Pregnant moms require an additional 25 grams per day above the
recommended dietary allowance (RDA), but this is easily met without dietary changes.
Adequate carbohydrates and protein are required to meet energy needs and for growth. If
inadequate carbohydrates are ingested, the body will turn to fat for energy needs and ketones
will be produced. Ketones will inhibit brain development of the fetus.

4. Vitamin needs: The demand increases during pregnancy, especially for the B vitamins.
The extra need is easily met through a normal diet, with the exception being folate. Folate is
needed for cell development and the synthesis of DNA, as well as for proper red blood cell
development. Without adequate folate, the pregnant mom may develop anemia. In addition,
there is a well-established link between higher incidents of neural tube defects with
inadequate folate intake prior to conception and early in the pregnancy. To ensure adequate
intake, careful menu planning and, in some instances, a supplement is recommended. All
grain products are now fortified with folate as a precautionary measure to lower the risk of
neural tube defects.

5. Increased mineral needs: During pregnancy, this is especially true of iodide, zinc, iron,
and calcium. Intakes of animal products, iodized salt, and fortified breakfast cereals will help
to meet the iodide and zinc requirements. Iron is required to make hemoglobin for red blood
cells. Women in general have a higher need than males due to loss during menstruation.
During pregnancy, however, extra iron is required due to increased blood volume as well as
to provide iron stores to the fetus. Iron deficiency anemia can lead to preterm delivery, low
birth weight infants, and increased risk for fetal death. Animal products are a good source of
iron as are fortified breakfast cereals. The absorption of the iron can be enhanced by simply
combining plant sources of iron with a rich source of vitamin C. Calcium is needed in the
formation of the baby’s teeth, bones, muscles, and heart. The fetus will rob the mom of her
stores if intake is inadequate.

6. Fitness and teratogens: Moderate levels of physical activity are encouraged daily. As
described above, teratogens are compounds that can increase the risk of a birth defect.
Known teratogens include: caffeine, drugs, alcohol, and tobacco. Tobacco use can increase
the risk for miscarriage, stillbirth, preterm delivery, and low birth weight infants. Alcohol is
linked to a risk for fetal alcohol syndrome, which results in physical and mental disabilities
and growth retardation. Drugs increase the risk for low birth weight, preterm delivery,
miscarriage, birth defects, and infant addiction.

7. A balanced diet: The dietary recommendations during pregnancy are important to ensure
proper nutrient intake. A balanced diet would consist of whole grains, a variety of fruits, a
variety of colorful vegetables, low-fat or fat-free dairy products, healthy fats, and protein.
Both animal and plant-based sources of protein should be included, with lean cuts of meat
being preferable. Processed meats should be avoided. Certain fish should also be avoided as
they may contain high levels of mercury. A prenatal vitamin may be prescribed by the
women’s doctor to meet any additional vitamin and mineral requirements. For further
information on dietary recommendations click here

Links to an external site. and visit the section for pregnancy and breastfeeding.

Aside from the nutrient needs specific to pregnancy, there are common changes that occur
during pregnancy that may impact mom’s appetite and nutrient intake. These include
heartburn, morning sickness, and constipation.

Heartburn occurs when the backflow of stomach acid enters the esophagus and causes a
burning sensation. Pregnant women are more susceptible to heartburn because hormones
produced by the placenta relax muscles in the gastrointestinal tract responsible for preventing
this backflow. To prevent heartburn, it is often recommended to avoid foods that trigger the
reflux (which can vary for each woman), spicy foods, and lying down for an hour after a
meal.

Morning sickness, or pregnancy-related nausea, may interfere with a women’s intake and
can be even triggered by the smell of food. Avoiding greasy foods, eating smaller meals,
having good ventilation when cooking, and avoiding large amounts of liquid at one time may
help alleviate the symptoms of morning sickness. Despite the name, morning sickness can
occur at any time during the day. While more common during the first trimester, the
symptoms can persist throughout the pregnancy. While annoying, these symptoms can be
often managed with dietary changes and present little nutritional risk.

Constipation, a condition defined by difficulty emptying the bowels, is also common among
pregnant women. As the fetus grows, intestinal muscles relax. As bowel movements require
the constriction of intestinal muscle, this relaxing often hinders the natural process. To
alleviate some of these complications, an increase in fiber from whole grains, fruits and
vegetables, as well as increased fluid consumption will help. Regular, moderate exercise with
your physician’s approval will also help to keep the GI tract functioning properly.

Additional Complications During Pregnancy

Other special situations during pregnancy can have more severe health consequences.

Physiological anemia occurs during pregnancy as the blood volume increases and the
concentration of red blood cells is diluted. If iron intake is too low to meet the increased
needs of pregnancy, anemia develops. As previously stated, this can have negative
consequences for both the mother and baby.
Gestational diabetes may occur after the 20th week of pregnancy, often occurring between
the 24th and 28th week of pregnancy. Hormones synthesized by the placenta may interfere
with insulin production and blood glucose control. As a result, blood glucose levels rise
because the insulin levels are insufficient to transport glucose from the blood to the cells.
Women over the age of 35, those with a family history of diabetes, and women who are
overweight are at risk for this condition. Although blood glucose levels often return to normal
following delivery, the mother has an increased risk of developing diabetes later in life.
Uncontrolled diabetes during the pregnancy can lead to a large baby, necessitating a C-
section and increased risk of trauma at birth.

Preeclampsia (pregnancy-induced hypertension) in the early form, or eclampsia in the

severe form, can be dangerous to both the mother and fetus. Edema, or swelling of the
tissues, occurs as well as increased blood pressure, protein in the urine, and changes in blood
clotting. Left untreated, kidney failure, convulsions, and death may result. Women under the
age of 17 or over 35, those with a family history of pregnancy-induced hypertension, and
overweight and obese women are most at risk. A good dietary intake with additional calcium
and potassium as well as limited sodium appears to help prevent this disorder.

Pica, an abnormal craving for both food and nonfood items, should be discussed with the
pregnant women’s physician. While a nightly craving for ice cream and dill pickles is
harmless, the desire to drink a floor cleaner or eat chalk is not. The cravings are usually
caused by a nutrient deficiency that, once corrected, eliminates the cravings.

Nutrition Post-Delivery
For moms who were concerned about their diet during pregnancy and wish to ensure proper
nutrition for their baby following birth, breastfeeding is a great choice. The American
Dietetic Association and the American Academy of Pediatrics recommend breastfeeding for
the first year of life. Although it is the preferred nourishment for the baby, the number of
women who choose to breastfeed falls below the recommendations as outlined by Healthy
People. There are a number of factors that can influence a women’s decision of whether to
breast-feed or bottle-feed her infant.

Education: Misinformation about breastfeeding can cause a woman to choose formula over
breast milk. Obstetricians and nurses can help dispel the misinformation and guide the new
mom through the process. Short hospital stays following delivery has had a negative effect on
the number of women who choose to breastfeed. New mothers need knowledge and support
over the first week to ensure that feeding is going well. Lactation consultants are a valuable
resource for information, and they provide help and support and answer questions as
concerns arise. As an additional resource, the La Leche League offers classes in breastfeeding
to provide support for breastfeeding moms. The classes can be found in most communities as
most have a local chapter.

Social concerns related to feeding the baby in public places: Women should be assured that
breastfeeding can be done modestly and successfully almost anywhere.

Working outside the home can make breastfeeding difficult. Breast pumps can be used to
secrete milk that can then be stored in the refrigerator or freezer. This milk can be used in a
bottle during the day while the baby can continue to nurse in the evenings. If this becomes
too difficult to manage, a combination of formula and breast milk may be a good
compromise.

Physical inability to nurse is a reality for some women—it is impossible to nurse due to
breast or nipple structure. For others, the demands of the baby are too great and the
production of milk is inadequate. Working with consultants and receiving the support and
advice from other moms may help solve the problems. In other cases, formula feeding may
be the best option for both the baby and the mom. In underdeveloped countries, breastfeeding
is usually the healthiest choice for the infant. Lack of sanitary water and limited education
about formula preparation could cause illness if the infant is formula fed.

Nutrition During Milk Production

During pregnancy, the body readies the breasts for breastfeeding by increasing the amount of
fat in the breast tissue and maturation of the structure. Hormones stimulate these changes and
produce sac-like structures in the breast for milk storage called lobules. After birth, the
hormone prolactin is secreted by the pituitary gland to produce milk. As the infant nurses,
the letdown reflex causes the release of milk from the milk ducts in the breasts. Oxytocin is
another hormone important for breastfeeding success. Oxytocin stimulates the lobules in the
breast, which in turn stimulates the letdown reflex. It normally takes 2-3 weeks for a feeding
routine to be established and for milk supply to meet demand. The first few days following
delivery, colostrum, a thick yellowish substance, is secreted from the breast. Colostrum is
rich in protein and immune factors, which protect the intestinal health of the newborn.
Several days following delivery, the milk composition changes, and although it has a thin
watery, bluish appearance, it is extremely high in nutritional quality. Interestingly, a mother’s
milk is able to change in order to meet her infant’s individual requirements. For instance, as
preterm infants may require more fatty acids for the synthesis of brain tissue and proper
central nervous system development, the milk composition changes to meet this need. While
formula is also an acceptable means to feed an infant, cow’s milk should never be given to a
child under 12 months of age. The level of protein and minerals in cow’s milk is too high for
the baby’s GI tract and makes it difficult to digest. The proteins contained in cow’s milk
could also lead to allergies later in life.

To ensure adequate milk production, the breastfeeding mom needs to take care of herself by
getting plenty of rest, finding a relaxed atmosphere in which to nurse, and eating healthy. The
nutrient needs during lactation are similar to what a woman needs during the second and third
semesters of her pregnancy. The requirement for vitamins A, E, C, and riboflavin as well as
several minerals increase. Calorie needs are higher during lactation than during pregnancy.
Hydration is especially important, and drinking approximately 13 cups of fluid per day will
allow adequate milk production. In general, a diet that provides at least 1800 calories,
moderate amounts of fat, and a variety of fruits, vegetables, whole grains, and dairy products
will meet the nutritional needs of the lactating female.

As an additional benefit, breastfeeding helps mom to recover more quickly from the
pregnancy and return to their pre-pregnancy weight. Breastfeeding is also convenient and
economical. However, while breastfeeding provides many advantages over bottle feeding
with formula, formula also meets an infant’s nutritional needs and promotes adequate growth.
A mother should be supported in whichever source of nutrition she chooses for her infant.
For women who are trying to decide if breastfeeding is the right choice, it may be helpful to
outline some of the benefits to both mom and the baby, as shown in Figure 6.1.

Breastfeeding is linked to a lower risk of these health problems:

In Infants: In Moms:
• Ear infections
• Type 2 diabetes
• Stomach viruses
• Breast cancer
• Diarrhea
• Ovarian cancer
• Respiratory infections
• Postpartum depression (PPD)
• Atopic dermatitis
• Asthma
• Obesity
• Type 1 and Type 2 diabetes
• Childhood leukemia
• Sudden infant death syndrome or
SIDS
• Necrotizing enterocolitis, a disease
that affects the gastrointestinal tract in
pre-term infants

Studies are still looking at the effects of breastfeeding on osteoporosis.

6.2: Infancy and Childhood

During the first year of life, an infant requires more nutrients and calories per pound of body
weight than during any other time of life. Rapid growth occurs as an infant will double their
weight during the first 4 to 6 months of life and triple it during the first year. Although
growth slows after the first year, intake is still important as adequate nutrients and calories
are necessary to support brain and physical growth. Children who do not receive adequate
nutrients are at risk for undernutrition, causing them to be short and underweight for their
age. Undernutrition is more prevalent in developing countries when breastfeeding ceases and
the child relies on rice as a main staple of the diet with minimal protein intake. In the United
States, undernutrition may occur due to poverty.

The best way to track an infant's or child’s growth is by using a growth chart. From birth to
36 months, the length, weight, and head circumference are recorded on a chart (Figure 6.2A).
An individual’s growth pattern can be tracked and compared to other infants of the same age
based on percentiles. These percentiles represent the rank of the infant relative to the same
age and gender. In practice, if an infant is stated to be in the 60th percentile for weight, then,
in a group of 100 babies, 59 would be smaller and 39 would be bigger.

For children ages 2-20, there are additional growth charts based on gender, weight, and
height for age (Figure 6.2B). In addition, the Body Mass Index (BMI) issued by the Center
for Disease Control (CDC) can be used as a tool to assess the growth of children and
adolescents as well as the risk for overweight and obesity in both adults and children. In
children, a BMI at 85% or higher can indicate a risk for obesity.
Figure 6.2 Growth Charts. (A) An example of an infant growth chart for boys relative to length and weight
and the respective percentiles is shown. (B) For children 2-20 years of age, a given percentile is calculated
relative to age and BMI.

Failure to thrive describes a condition in children younger than 2 years of age where poor
growth is observed. In some cases, an inadequate intake is due to a disease such as constant
diarrhea, intestinal issues, or some other physical (or health) problem. In most cases, failure
to thrive occurs due to inadequate feeding practices. Parents may be inexperienced and need
proper education on the care and feeding of the child. Alternatively, they may simply lack the
resources for food procurement. By tracking growth patterns, physicians will be alerted to the
delayed growth and interventions can be initiated. If not addressed, failure to thrive can lead
to poor growth, impaired mental development, and behavioral issues.

As previously discussed above, human milk or infant formula should make up the total diet
for approximately the first 6 months of life. Even after solid food is introduced, human milk
or formula should continue to be given during the first year. Infants require 2-4 times more
calories per kilogram of body weight than what an adult requires. Both breast milk and infant
formulas are rich in fat to provide a concentrated source of calories as well as the fat needed
for brain and nervous system development. Arachidonic acid (AA) and docosahexaenoic
acid (DHA) are long chain fatty acids essential for brain and eye development. Human milk
provides both these fatty acids, especially if the mother eats fish. Recently infant formula has
been supplemented with both fatty acids as well. Carbohydrate and protein needs can be met
with a varied diet with typical intake of human milk or formula and solid foods. Excess
protein should be avoided to prevent putting stress on the infant’s kidneys as they try to clear
the waste products that result from protein metabolism. Excess consumption or early
introduction of proteins can lead to a food allergy as the infant’s immune system reacts to the
protein.

If chosen to be used, formulas provide all the vitamins an infant requires aside from vitamin
K, while breast fed infants require a vitamin D supplement. If the nursing mother is a vegan,
the infant will also require vitamin B-12 supplementation. All infants regardless of the type
of milk they consume are given a vitamin K shot at birth. The vitamin K injection is given to
prevent a rare but potentially fatal bleeding disorder in newborns.

Just as in pregnancy, iron is crucial for mental development. A lack of iron leads to anemia.
If anemia is left untreated, the infant may experience long-term effects of impaired mental
development, motor development, and behavioral issues later in life. For this reason, iron
fortified infant formula is recommended for infants that are not breast fed. Breast fed infants,
however, should have adequate amounts of iron provided in the milk until around 6 months
of age when solids are introduced. If the mother was iron deficient during the pregnancy or
while nursing, the infant may require a liquid iron supplement.

In most cases, both human milk and formulas provide enough water to meet the infant’s
needs. If dehydration occurs due to diarrhea, vomiting, fever, or excess sun exposure,
supplemental water should be given. Signs of dehydration include: dark yellow or strong-
smelling urine, lack of wet diapers, dry mouth and lips, lethargy, and absence of tears when
crying. Extreme dehydration requires medical attention to prevent loss of kidney function.

Nutrition: 6-12 Months of Age

At around 6 months of age, solid foods may be introduced into the diet. Parents should watch
for physical cues that their infant is ready for solid foods. Sometime between 4 to 6 months
of age, the infant will gain head and neck control and be able to sit up with support. The
extrusion reflex, thrusting of the tongue forward to push food out of the mouth, will
disappear. By this time, the digestive tract and the kidneys have matured, and the infant can
properly digest starches and excrete waste products from protein. In terms of protein sources,
whole proteins are better absorbed, and the risk for developing allergies is decreased.

When the infant is ready for solids, baby cereal is typically introduced first. Begin with a
teaspoon of iron fortified baby cereal and gradually increase the amount over the next seven
days. After a week, the next food can be introduced. It is important that new foods be
introduced 7 days apart to monitor for any signs of an allergy. After cereals are introduced,
vegetables, fruits, meats, and egg yolks can be gradually added. There is no order to
introduce the foods but many pediatricians recommend introducing vegetables before fruits.
Allergy-causing foods such as eggs, dairy, soy, peanuts, and fish are now being introduced
after 4-6 months of age. Parents should follow the advice of their child’s physician when
introducing solid foods to their infant. By one year of age, the infant should be consuming a
variety of foods. Commercial baby foods can be used, or a parent may make their own baby
food by pureeing or grinding food at home. If this is the case, adding seasonings and spices to
the food is unnecessary. There are several foods that should never be given to a child under
one year of age.

Avoid the following:

 1. Honey, which may contain spores of Clostridium botulinum, could lead to a food-
borne illness known as botulism. While the spores are harmless to an older child or
adult, they can be fatal in a child younger than one year.
2. Choking hazard foods. Examples include small round foods (such as grapes or hot
dogs), sticky foods (like peanut butter), and hard foods (like candy and popcorn).
3. Excess juice such as apple or pear juice. Excess juice may be replacing human milk
or formula, and the infant may be not getting enough calcium for bone development.
Excess juice can also lead to failure to thrive if juice is consumed instead of solids,
and it has also been linked to poor dental health and obesity. Apple and pear juice also
contain fructose and sorbitol, which can lead to diarrhea.
4. Cow, goat, and unpasteurized milk should be avoided due to the inability to digest
the proteins in both cow and goat milk before one year of age. Unpasteurized milk
poses a health risk for everyone and may result in food poisoning.

Feeding time should be a pleasant experience for the care giver and the infant. Stay calm
when feeding the infant, and expect that a new food will need to be introduced several times
before it is successfully received. By 6-7 months self-feeding skills can be practiced as
coordination develops, and the infant is eager to explore and experiment with food. More
information can be found at the American Academy of Pediatrics

Links to an external site. website.

Note: At times parents or physicians mistakenly think that providing infant cereal prior to 6
months will enable an infant to sleep through the night. As sleep patterns are a
developmental (not a digestive) milestone, it is rare that solids are needed prior to 6 months.

Nutrition: 2-5 Years of Age

Between the ages of 2 and 5 a toddler’s growth slows and appetite declines. Trying to meet
nutrient needs can become more difficult but can be accomplished with careful meal planning
and the addition of snacks. For preschoolers, the website ChooseMyPlate, provides
information on healthy meals and snacks. The recommendations for physical activity at this
age can be found in the Physical Activity Guidelines for Americans, 2nd edition.

Preschoolers, ages 3-5, should be physically active throughout the day. Offering nutrient-
dense foods with limited sugar, fat, and sodium will help to establish a healthy eating pattern
that can be followed for the rest of the child’s life. A parent’s job is to be a good role model,
offering and demonstrating positive eating behaviors by eating a variety of foods. It is the
child’s responsibility to determine how much and what they eat. Offering foods in a variety
of ways, such as steamed vegetables with cheese sauce, cooked vegetables, or raw vegetables
with dip, may help improve acceptance. The one bite rule encourages the child to try one
bite of each food. Children develop food preferences and often experience food jags—the
desire to eat the same foods or only a certain color at each meal. Most often, if caregivers
continue to offer a variety of foods at meal and snack times, the child will begin to eat a
variety of foods, and the jag will disappear. It is important to also note that preschool children
have more taste buds than adults and are more sensitive to taste. As such, crisp textures,
colorful foods, mild flavors, and finger foods are generally well accepted. To make meal time
a more pleasant experience, try allowing preschoolers the opportunity to help with the meal
by choosing fruits/vegetables at the store, mixing a salad, and incorporating new foods with
those that are well accepted. Despite their best efforts, all parents will experience some
common feeding difficulties with their preschoolers:

My child is a picky eater. Preschoolers have small stomachs, and, as adults, we often
overestimate how much they need to consume. A good measuring tool for intake should be 1
tablespoon of fruits, vegetables, and meat/beans per year of life. Children should be allowed
to determine the amount of grains and milk to consume based on their appetite. If excess milk
is consumed, parents may need to limit intake to allow for adequate intake of the other food
groups. Children should be allowed to express their independence and their food preferences,
which may be based on food temperature, taste, appearance, and texture. Parents can
encourage this by offering a variety of healthy foods, allowing children to make their choices
and avoiding nagging, force feeding, and bribery at meal times. Remember, eating habits
over the course of a week are more important than choices at one meal.

My child always wants a snack. Because children have small stomachs, snacks are actually
very important. Offering 6 small meals through the day and focusing on nutrient-dense
choices will enable your child to meet her nutrient needs. One caution, offering beverages
like juice, diet soda, or even milk in large quantities will decrease the amount of solid foods
consumed. Whole fruits and vegetables are better choices than juice and water with some of
the snacks as they can provide many benefits. If juice is offered, no more than 4-6 ounces per
day should be consumed by children ages 1 to 6, while no more than 8-12 ounces per day
should be consumed by children ages 7 to 18.

My child won’t eat vegetables. Fruits are often better accepted than vegetables, likely
because the natural sugar in fruits make them slightly sweet. Encourage your child to eat the
rainbow. Look through magazines together or examine the different fruits and vegetables at
the grocery store and their many colors. The more color on the plate, regardless of whether
the food is a fruit or vegetable, the more nutrients. Having the child help prepare the
vegetable and offering it in a variety of ways may improve acceptance.

A preschooler or toddler who eats a variety of foods from the various food groups is likely
meeting his or her nutrient needs. In most cases, a multivitamin is not recommended for
children. The exceptions would include a child who is ill and unable to eat a healthy diet or
one with very erratic eating habits. In such cases, the American Academy of Pediatrics states
that a child may benefit from a children’s multivitamin that does not exceed 100% of the
Daily Values. However, the focus should be on healthy foods rather than a supplement.

In cases where a child’s nutrient needs are not being met, various signs and symptoms may
appear. Three common conditions that can affect preschoolers are:

1. Iron deficiency anemia usually manifests itself between the ages of 6 and 24 months.
Anemia causes the oxygen supply to the cells to decline and can lead to decreased
energy and learning ability as well as decreased immunity and increased risk of
disease. Iron fortified breakfast cereal and a small amount of meat will provide
enough iron to meet children’s needs.
2. Constipation may be related to a medical condition but is usually caused by other
factors. Increasing fiber through fresh fruits and vegetables, whole grains, cereals, and
beans will help relieve constipation. Consuming 4-5 cups of fluid daily is important
with the additional fiber intake. Having the child to go to the bathroom when they feel
the urge should be encouraged.
 3. Dental caries (cavities) occurs when sugar from beverages or food lie on the teeth or
gums for an extended period of time. To prevent cavities from developing, never put a
baby to bed with a bottle of milk, formula, or juice. Wipe your infants gum and teeth
after drinking or eating. For toddlers and preschoolers, avoid sticky, high sugar snacks
and encourage brushing with a small amount of fluoridated toothpaste.

Other subgroups of preschoolers who require specific diet plans are children who follow total
vegetarian diets and those with autism. For children who avoid animal products, emphasis
should be placed on an adequate intake of plant sources of protein, vitamin D, vitamin B-12,
calcium, iron, and zinc, all of which are abundant in animal products but require careful meal
planning for vegetarians. Nutritional intervention for Autism spectrum disorder is in the early
stages of research. Currently recognized, evidence-based nutritional treatment includes
gluten-free, casein-free diet and supplements of vitamin B-6, magnesium, probiotics, and
essential fatty acids.

Nutrition: The School-Age Years (Preteen)

The school age years bring additional nutritional challenges. During this period of time,
varying degrees of control are lost by caregivers while increased pressure from peers, the
media, and even the child’s own exertion of their independence all play a role when making
food choices. As such, few school-age children actually meet their daily requirements from
all five of the food groups. Their diets tend to be lacking in calcium, iron, and zinc while
(often) high in sugar and fat. To promote healthy eating habits for children, websites such as
Choosemyplate.gov

Links to an external site. use interactive games, activity sheets, and videos for kids. Parents
will also find resources and education about proper nutrition for children.

There are also special concerns that occur during the school age years that may impact a
child’s nutritional status:

Lack of regular meal times. This is particularly true of breakfast. Consumption of regular
meals is important, but often breakfast is sacrificed so that the child can get an extra 10
minutes of sleep. In other cases, kids just do not like breakfast foods or are not hungry first
thing in the morning. Breakfast is important because, as the name implies, you are "breaking
the fast." Your body requires fuel for physical activity and brain activity. For children to meet
their daily requirements of vitamins and minerals, kids must eat breakfast. Ready-to-eat
breakfast cereal is a good source of iron, vitamin A, and folic acid. However, there are no
limits on what can be eaten for breakfast. Leftovers from dinner, yogurt sprinkled with
granola, pizza, cheese sticks, dried fruit, or even a sandwich can be eaten for breakfast. The
key is combining a good source of protein with a carbohydrate to jump-start your day and
provide energy to carry you through until lunchtime.

Excess consumption of saturated fat. All foods can be eaten in moderation and that
includes an occasional treat that is high in fat or sugar. The problem is that most children are
consuming excess fat in their daily diet. Small diet changes can lower fat consumption
without compromising flavor. Strategies to significantly decrease the amount of fat in the
food range from switching to low-fat milk and part-skim cheese, substituting lean ground
turkey for ground beef, taking the skin off chicken, and baking or broiling instead of frying
foods. Over restriction of fat, however, is not a good idea. It often results in the “good food,
bad food” attitude and is linked to eating disorders later in life.

Increasing incidence of overweight and obesity. Childhood obesity is a serious health

risk—approximately 40% of obese children become obese adults. There are many factors
contributing to this growing health risk: Supersized portions, fast food, convenience foods,
increased soft drink consumption, and easy access to sugar-laden snack foods. Coupled with
a lack of physical activity, often related to decreased gym time at school, a lack of safe play
areas, and increased TV viewing time, it becomes easy to see why the incident of overweight
and obese children continues to increase. Although it may be easy to figure out why children
are gaining weight, resolving the issue is not as simple. For instance, while most adults
undertake a diet to lose weight, this is not the best approach with children. The first step in
addressing the problem is to look at how much physical activity the child gets in a day’s time.
Health professionals recommend at least 60 minutes of moderate to vigorous physical activity
per day for children and teens.

Healthy Tip: Getting kids interested in physical activity for fun and enjoyment can help them
reach a healthy weight and will set up physical activity patterns for the remainder of their
lives. Families can play together by taking a walk, riding bikes, or trying a new sport such as
rollerblading. Enrolling kids in community leagues or classes that focus on fun rather than
competition can provide them with a variety of activities so that they can discover something
they enjoy.

In addition to the physical activity, moderate calorie intake is important. Limiting high-
calorie foods and focusing on nutrient-dense choices can help the child grow into their
weight. Understanding portion sizes and making small changes in food preparation will allow
the child to continue to enjoy foods that they like and not feel deprived. It is tough to be an
overweight child. Aside from the health risks associated with being overweight, kids must
deal with the social ridicule and embarrassment and isolation that often occur at school.

Early onset of cardiovascular disease and type 2 diabetes. Previously, heart disease and
type 2 diabetes were usually found in overweight middle-age individuals. Today, physicians
are diagnosing a high number of children with both type 2 diabetes and high cholesterol
levels. Early screening is advised and treatment includes a balanced diet and physical activity
to help the child achieve a healthy weight. Once achieved, the symptoms of diabetes and high
blood pressure generally resolve.

Nutrition: The Teenage Years

The teenage years bring yet another period of rapid growth and development. In females,
growth normally occurs between the ages of 10 and 13. Females will grow in height and
begin to accumulate both lean and fat tissue. During this period of time, sexual development
and menstruation begins. In males, growth occurs between the ages of 12 and 15 and much of
the body weight is from lean tissue. On average, males experience a growth in height of
approximately one foot. During this period of growth, appetites increase substantially.
However, satisfying their hunger often trumps any thought of eating healthy. Temptations are
also everywhere, whether it is advertisements aimed at teens, soft drink machines being made
available at school, or the increased access to fast foods, sugary beverages, and sugar-laden
snack foods, all of these options tend to replace nutrient-dense food choices. Peer pressure,
concern over physical appearance, and exertion of their independence also affect food
choices. As was the case in the initial school age years, most teenagers’ diets are low in
calcium, iron, zinc, fat-soluble vitamins, and folate. Parents can gently guide teens toward
healthier choices by modeling good food habits at home, discussing the role that nutrition
plays in their development both now and in the future and health risks from poor dietary
habits that occur later in life, and encouraging wise food choices when eating at restaurants.

Several programs are available to ensure that all families have access to healthy food. After
all, adequate calories and nutrient dense food choices are needed for a child to grow and
learn.

Supplemental Nutrition Assistance Program (SNAP): Formerly known as the Food Stamp
program, this program provides an access card to low-income families to assist in the
purchase of food.

Women, Infant and Children (WIC): The program is available to low-income pregnant
moms, lactating moms, infants, and children up to the age of five years. Specific food,
formula, and baby foods may be purchased for the participants.

School Lunch and School Breakfast programs: Low-income families may qualify for free
or reduced-price meals at school. In many school districts, breakfast is now free for any child.
Some schools also have the summer lunch program to ensure that low-income children
receive a hot meal daily. Other schools have the backpack program where children who
qualify receive a backpack with shelf-stable food items to provide food over the weekend.

6.3: Adulthood
Nutrition: Adulthood
It is important to remember, food choices are important at every stage of life, not just the
early and growing stages. Healthy living, which includes exercise and making wise food
choices based on ChooseMyPlate recommendations, should be a part of daily life. Making
healthy decisions can help prevent diseases that commonly manifest themselves in middle
age. Illness such as hypertension, diabetes, cardiovascular disease, osteoporosis, and obesity
can be controlled or even prevented. Contrary to popular belief, a decline in health is not
inevitable as we age. Aging is not a disease, and advances in health care and food safety and
sanitation have allowed many to add years to their life. In fact, the fastest growing population
in the United States are those 85 years of age and older. As such, preventing chronic disease
in this population is important not only for quality of life and independence but also to
prevent overburdening the health care system.

Adulthood is divided into four stages each with their own unique needs: ages 19-30, ages 31-
50, ages 51-70, and greater than 70 years. The first two stages from 19 to 50 are considered
young adulthood. During this transition stage, adults are often exploring their independence,
establishing a career, and beginning a family of their own. Middle adulthood encompasses
the ages of 51 to 70. During this period, individuals are usually juggling multiple schedules
(home, children, work), adjusting to the "empty nest syndrome" (no longer have children in
the house), and dealing with elderly parents. Older adulthood refers to anyone over the age
of 70. This is often the period of downsizing, retirement, loss of a spouse, and dealing with
one’s own mortality.

Unlike other stages of the lifecycle, aside from pregnancy, there is no growth occurring.
Adulthood is a period of body function maintenance until approximately age 30. After age
30, we experience both physical and physiological changes that occur in body structure and
function. This change is referred to as aging. Although aging occurs throughout adulthood,
until age 30, rates of cell synthesis and breakdown are in balance. After age 30, the
breakdown occurs faster than cell synthesis, and this leads to a decline in body functions.
However, degenerative or chronic diseases do not have to be accepted as part of the aging
process. A healthy lifestyle, including a nutritious diet, exercise, adequate sleep, and avoiding
poor lifestyle choices (such as smoking and excess alcohol consumption), can prevent or
reverse age-related changes.

Usual aging refers to the expected progression of cell death with age and the physical
changes that occur related to unhealthy lifestyle choices. Examples include loss of bone mass,
weight gain, high blood pressure, and decreased lean body mass. Conversely, physical and
physiological changes that occur related to growing older but not related to poor lifestyle
choices are called successful aging. These individuals age at a slower rate and experience
age-related diseases later than usual agers. Delay of disabilities caused by age-related disease
is called compression of morbidity. Several factors that directly affect an individual’s aging
process include (1) heredity, (2) lifestyle, and (3) environment.

Heredity: Our genetic composition (genes) play a role in how long we will live. A family
history of longevity can provide the potential for a long life. In terms of longevity, females,
on average, tend to live longer than males. Metabolic rates can also impact one’s lifespan.
For example, some people have a thrifty metabolism that causes them to store fat more easily
(this was especially helpful for our ancestors who had to hunt and gather food). The ability to
store fat provided insulation as well as a storage source of energy during the lean times.
Today, a thrifty metabolism may be detrimental, as society has shifted to one of inactivity
with a plentiful supply of food. Relative to nature versus nurture, your genes (nature) can
have an impact on your longevity, but lifestyle and environment (nurture) also play a role.

Lifestyle: This includes eating and exercise habits and lifestyle choices such as tobacco or
alcohol use. The highest life expectancy in the world is in Okinawa, a Japanese island in the
East China Sea, where a typical diet is plant-based with rice and fish as staples. Nations that
follow the Mediterranean diet, a diet that is high in seasonally fresh, locally grown foods,
fish, limited red meat, dairy products, and a focus on olive oil as the main fat, are also known
to have longer lives with the least incidence of disease. Moderate wine consumption with
meals also has heart health benefits.

Environment: The ability to make our own decisions is important for everyone. Many of our
decisions are based on our environment and circumstances. Education and available
resources are important in the decisions we make related to meal choices and health care.
Adequate shelter provides safe living conditions and protects us from the elements and
physical danger. Sufficient income is necessary for purchasing food and shelter. If any of
these are missing or inadequate, the impact to our health can be negative and speed up the
aging process.
As an adult, food choices become very important as calorie needs decline, but adequate
nutrition remains very important. The consumption of nutrient-dense foods will delay the
onset of some diseases; increase our physical, mental, and social well-being; improve our
immune system; and aid in recovery from illness.

The Dietary Guidelines

Links to an external site., in addition to ChooseMyPlate

Links to an external site., provide a good overview of choices adults can make to decrease the
quantity of their food intake while increasing the quality. The Dietary Guidelines recommend
a diet low in saturated and trans fats in conjunction with a diet that is low in cholesterol,
simple sugars, and sodium. The diet should focus on plant-based foods with minimal
processing, fish, whole grains, low-fat dairy products, and small amounts of meat.
Recommendations also include maintaining a healthy weight through daily exercise and
increasing awareness of safe food handling practices in order to avoid food borne illness.
However, despite these recommendations, many adults continue to consume excess calories,
fats, sodium, and alcohol. By utilizing complex carbohydrates rather than simple
carbohydrates, one can lower their risk for colon cancer and heart disease, prevent
constipation, and lower blood cholesterol levels.

Nutrients often lacking in the older individuals’ diet include potassium, calcium, vitamin D,
vitamin B12, carotenoids, dietary fiber, and minerals such as iron, zinc, and magnesium. To
ensure that older adults get enough of these nutrients in their diet, the dietary approach
DASH (Dietary Approach to Stop Hypertension) was developed. The focus is on using
herbs and spices to replace sodium and the daily consumption of a variety of colorful fruits
and vegetables, three servings of low fat/fat-free dairy products, and whole grains fortified
with vitamin B12.

Adequate water intake is also important as we age. As we age, we lose our thirst sensation,
and by the time we realize we are thirsty, we are dehydrated. In fact, many adults confuse
thirst with hunger, which further compounds the state of dehydration. If inadequate fluids are
consumed, symptoms of dehydration occur which include: disorientation and mental
confusion, constipation, bowel impaction, and eventually death.

Additional issues related to aging can also have an impact on our food choices. Physical
disabilities may limit our ability to cook or shop for food. Dental issues, such as lack of teeth
or ill-fitting dentures, can negatively affect intake of meats. Taste acuity declines, and our
desire to eat may decrease. Social isolation or lack of income may limit our food choices or
number of meals eaten. As such, many older adults may benefit from a multi vitamin and
mineral daily to supplement their intake. A multivitamin/mineral supplement that provides
100% of the Daily Value will help meet these nutrient needs.

There are two main factors that are related to the nutrient needs of adults and nutrition
concerns that occur with aging. These factors are physiological and psychosocial each with
multiple components. The impacts from both physiological and psychosocial factors related
to aging are discussed below.

Physiological Factors
 1. Body composition changes are a normal part of aging. Sarcopenia, a loss of lean
muscle, leads to a decreased basal metabolic rate. As the change occurs, there is an
increase in fat stores known as sarcopenic obesity. Aging typically leads to a more
sedentary lifestyle that can cause decreased mobility, joint issues related to increased
weight and decreased physical activity, as well as decreased flexibility.
2. Skeletal system changes occur as bone loss related to osteoporosis and decreased
bone mass progresses in both males and females. Adequate vitamin D and calcium as
well as a review of medications should be addressed to maintain bone mass.
3. Digestive system changes are common in older adults related to lactose
malabsorption and decreased stomach acid. Constipation is a common complaint
among the elderly due to lack of fluids, fiber, and exercise as well as decreased GI
motility. Gallbladder, liver, and pancreas functions also decline with age.
4. Chronic disease related to malnutrition, altered nutrient utilization, and altered
nutrient needs affects many of the elderly. Those 65 and older who are in an
institutional setting are at risk.
5. Medications can negatively impact nutritional status. Medications can lead to loss of
taste or smell, induce anorexia, or interact and inhibit the absorption of nutrients.
Antibiotics can disrupt the natural bacteria in the GI tract and deplete vitamin K
levels. Diuretics can lead to a loss of potassium, and a supplement may be necessary.

Psychosocial Factors
1. Social isolation related to lack of support from family and friends can lead to a poor
intake.
2. Depression can lead to social withdrawal, poor appetite, weight loss, and
malnutrition.
3. Alzheimer’s disease or dementia causes loss of memory, confusion, and decreased
social contact.
4. Economic factors can lead to an inability to purchase food or nutrient-dense food
choices affecting both the quality and quantity of the diet.

A screening tool can be used to evaluate an elderly individuals risk for malnutrition related to
both physiological and psychosocial factors. The nutrition screening initiative tool is
commonly known as DETERMINE—a nutrition checklist that can be performed by medical
personnel, family members, and even the older person themselves to evaluate the individual’s
needs. The acronym stands for:

Disease: Alzheimer's disease, cancer, heart disease, or others

Eating poorly

Tooth loss

Economic hardship

Reduced social contact

Medications
Involuntary weight loss

Needs assistance

Elderly, older than 80 years of age

If an older adult is at risk, the medical community can provide education and resources to the
family to help the individual obtain the help that is required. Nutrition programs for
individuals over 60 include congregate meal programs, Meals-on-Wheels, SNAP, food
coops, and religious and social organizations. The U.S. Federal Government subsidizes meals
for seniors served in a community setting through the congregate meal programs. Meals-on-
Wheels is also subsidized by the government and is a home delivery program. One or two
meals can be delivered five days per week. Home Health care agencies and Adult Daycares
are other options to help meet the needs of the older population. To learn more about
programs for the elderly visit the National Institute on Aging website

Links to an external site. or the American Geriatrics Society website

Links to an external site.. An exercise guide, Exercise and Physical Activity: Your Everyday
Guide, can be downloaded for free from the National Institute on Aging website.

The USDA has recommended a specific intake of the food groups to meet the unique nutrient
needs of the older population. In general, recommendations include:

1. Increased nutrient density

2. Adequate fluid and fiber intake
3. Lean meats to provide iron, protein, zinc, and vitamin B-6 and B-12, which are
frequently inadequate
4. Use of a multivitamin and mineral supplement
5. Modified physical activity to maintain lean body tissue and prevent unwanted weight
gain from fatty tissue.

In summary, aging is inevitable, but by choosing a diet based on ChooseMyPlate

recommendations and the Dietary Guidelines, adults can avoid numerous health issues and
diseases, maintain body function, and age successfully.