INSTRUCTOR MANUAL For Nutrition Through the Life Cycle. 8th Edition by Judith E. Brown by StudyGuide

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 1: NUTRITION BASICS

TABLE OF CONTENTS Purpose and Perspective of the Chapter .......................................................................... 2 List of Student Downloads ................................................................................................ 2 Chapter Objectives ............................................................................................................. 2 Complete List of Chapter Activities and Assessments .................................................... 2 Key Terms ........................................................................................................................... 3 What's New in This Chapter............................................................................................... 7 Chapter Outline ................................................................................................................... 7 Discussion Questions........................................................................................................ 10 Additional Activities and Assignments .............................................................................12 Additional Resources ........................................................................................................ 19 Cengage Video Resources .................................................... Error! Bookmark not defined. External Videos or Playlist ................................................... Error! Bookmark not defined. Internet Resources.................................................................................................................. 19 Primary Sources....................................................................................................................... 19 Cengage Audio Resources .................................................... Error! Bookmark not defined. External Audio Resources .................................................... Error! Bookmark not defined. List of Transcripts for Audio Assignments ....................... Error! Bookmark not defined.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to introduce or refresh the students’ memory of basic nutrition knowledge. The chapter will present information about how nutrition paves the way to an understanding of needs and benefits related to nutrition by life-cycle stage. The 10 principles of nutrition will be discussed, as will how each serves a purpose to provide a larger understanding of nutrition and its relationship to overall health. Four public food and nutrition programs are discussed, and readers will be able to identify the basic elements of each, while also being able to design a healthy dietary pattern.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 1.1 Understand the meaning of the nutrition concepts presented. 1.2 Read and understand the elements of nutrition labels; you will be able to understand the nutritional value of most food products. 1.3 Cite two examples of how nutrient needs change during the life cycle and how nutritional status at one stage during the life cycle can influence health status during another. 1.4

Describe the components of individual-level nutrition assessment.

1.5

Identify the basic elements of four public food and nutrition programs.

1.6 Design a healthy dietary pattern.

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

KEY TERMS Nutrients: Chemical substances in foods that are used by the body for growth and health. Food security: Access at all times to a sufficient supply of safe, nutritious foods. Food insecurity: Limited or uncertain availability of safe, nutritious foods, or the ability to acquire them in socially acceptable, legal ways. Calorie: A unit of measure of the amount of energy supplied by food. Also known as the “kilocalorie” (kcal), or the “large Calorie.” Essential nutrients: Substances required for growth and health that cannot be produced, or produced in sufficient amounts, by the body. They must be obtained from the diet. Essential amino acids: Amino acids that cannot be synthesized in adequate amounts by humans and therefore must be obtained from the diet. Also called indispensable amino acids. Nonessential nutrients: Nutrients required for growth and health that can be produced by the body from other components of the diet. Daily values (DVs): Scientifically agreed-upon standards for daily intakes of nutrients from the diet developed for the use on nutrition labels. Insulin resistance: A condition in which cell membranes have a reduced sensitivity to insulin so that more insulin than normal is required to transport a given amount of glucose into cells. Type 2 diabetes: A disease characterized by high blood glucose levels due to the body’s inability to use insulin normally, to produce enough insulin, or both. Glycemic index: A measure of the extent to which blood glucose levels are raised by consumption of an amount of food that contains 50 g of carbohydrate compared to 50 g of glucose. A portion of white bread containing 50 g of carbohydrate is sometimes used for comparison instead of 50 g of glucose. Amino acids: The “building blocks” of protein. Unlike carbohydrates and fats, amino acids contain nitrogen. Nonessential amino acids: Amino acids that can be readily produced by humans from components of the diet. Also referred to as dispensable amino acids.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

Kwashiorkor: A severe form of protein-energy malnutrition in young children. It is characterized by swelling, fatty liver, susceptibility to infection, profound apathy, and poor appetite. The cause of kwashiorkor is unclear. Fatty acids: The fat-soluble components of fats in foods. Glycerol: A component of fats that is soluble in water. It is converted to glucose in the body. Essential fatty acids: Components of fat that are a required part of the diet (i.e., linoleic and alpha-linolenic acids). Both contain unsaturated fatty acids. Prostaglandins: A group of physiologically active substances derived from the essential fatty acids. They are present in many tissues and perform such functions as the constriction or dilation of blood vessels and stimulation of smooth muscles and the uterus. Thromboxanes: Biologically active substances produced in platelets that increase platelet aggregation (and therefore promote blood clotting), constrict blood vessels, and increase blood pressure. Prostacyclins: Biologically active substances produced by blood vessel walls that inhibit platelet aggregation (and therefore blood clotting), dilate blood vessels, and reduce blood pressure. Saturated fats: Fats in which adjacent carbons in the fatty acid component are linked by single bonds only (e.g., -C-C-C-C-). Unsaturated fats: Fats in which adjacent carbons in one or more fatty acids are linked by one or more double bonds (e.g., -C-C=C-C=C-). Monounsaturated fats: Fats in which only one pair of adjacent carbons in one or more of its fatty acids is linked by a double bond (e.g., -C-C=C-C-). Polyunsaturated fats: Fats in which more than one pair of adjacent carbons in one or more of its fatty acids are linked by two or more double bonds (e.g., -CC=C-C=C-). Trans Fat: A type of unsaturated fat present in hydrogenated oils, margarine, shortenings, pastries, and some cooking oils that increase the risk of heart disease. Fats containing fatty acids in the trans versus the more common cis form are generally referred to as trans fat. Cholesterol: A fat-soluble, colorless liquid primarily found in animal products. Dietary pattern: The quantities, proportions, variety, or combination of different foods, drinks, and nutrients in diets, and the frequency with which they are habitually consumed. Coenzymes: Chemical substances that activate enzymes.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

Metabolism: The chemical changes that take place in the body. The conversion of glucose to energy or body fat is an example of a metabolic process. Antioxidants: Chemical substances that prevent or repair damage to cells caused by exposure to oxidizing agents such as oxygen, ozone, and smoke and to other oxidizing agents normally produced in the body. Many different antioxidants are found in foods; some are made by the body. Phytochemicals: (phyto = plants) Chemical substances in plants, some of which affect body processes in humans that may benefit health. Also called phytonutrients. Homeostasis: Constancy of the internal environment. The balance of fluids, nutrients, gases, temperature, and other conditions needed to ensure ongoing, proper functioning of cells and, therefore, all parts of the body. Malnutrition: The cellular imbalance between the supply of nutrients and energy and the body’s demand for them to ensure growth, maintenance, and specific functions. Primary malnutrition: Malnutrition that results directly from inadequate or excessive dietary intake of energy or nutrients. Secondary malnutrition: Malnutrition that results from a condition (e.g., disease, surgical procedure, medication use) rather than primarily from dietary intake. Nutrigenomics: The study of diet- and nutrient-related functions and interactions of genes and their effects on health and disease. Chronic disease: Slow-developing, long-lasting diseases that are not contagious (e.g., heart disease, cancer, diabetes) and are the result of a combination of genetic, physiological, environmental, and behavioral factors; also known as “noncommunicable diseases.” Hypertension: High blood pressure. It is defined in adults as blood pressure exerted inside blood vessel walls that typically exceeds 140/90 mmHg (millimeters of mercury). Stroke: An event that occurs when a blood vessel in the brain ruptures or becomes blocked. Stroke is often associated with “hardening of the arteries” in the brain. Also called cerebral vascular accident. Alzheimer’s disease: A brain disease that represents the most common form of dementia. It is characterized by memory loss for recent events that expands to more distant memories over the course of 5 to 10 years. It eventually produces profound intellectual decline characterized by dementia and personal helplessness.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

Chronic inflammation: Low-grade inflammation that lasts weeks, months, or years. Inflammation is the first response of the body’s immune system to infectious agents, toxins, or irritants. It triggers the release of biologically active substances that promote oxidation and other reactions to counteract the infection, toxin, or irritant. A side effect of chronic inflammation is that it also damages lipids, cells, and tissues. Oxidative stress: A condition that occurs when cells are exposed to more oxidizing molecules (such as free radicals) than to antioxidant molecules that neutralize them. Over time, oxidative stress causes damage to lipids, DNA, cells and tissues. It increases the risk of heart disease, type 2 diabetes, cancer, and other diseases. Energy-dense foods: Foods that have relatively high-calorie values per unit weight of the food. Empty-calorie foods: Foods that provide an excess of calories relative to their nutrient content. Nutrient-dense foods: Foods that contain relatively high amounts of nutrients compared to their caloric value. Dietary supplements: Any product intended to supplement the diet, including vitamin and mineral supplements, proteins, enzymes, amino acids, fish oils, fatty acids, hormones and hormone precursors, and herbs and other plant extracts. In the United States, such products must be labeled “Dietary Supplement.” Enrichment: The replacement of thiamin, riboflavin, niacin, and iron lost when grains are refined. Fortification: The addition of one or more vitamins or minerals to a food product. Prebiotics: Certain fiberlike forms of indigestible carbohydrates that support the growth of beneficial bacteria in the lower intestine. Nicknamed “intestinal fertilizer.” Probiotics: Strains of lactobacillus and bifidobacteria that have beneficial effects on the body. Also called “friendly bacteria.” Registered Dietitian Nutritionist (RDN): An individual who has acquired food and nutrition knowledge and skills necessary to pass a national registration examination and who participates in continuing professional education. Anthropometry: The science of measuring the human body and its parts. Nutrition surveillance: Continuous assessment of nutritional status for the purpose of detecting changes in trend or distribution in order to initiate corrective measures.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

Nutrition monitoring: Assessment of dietary or nutrition status at intermittent times with the aim of detecting changes in dietary or nutritional status of a population. [return to top]

WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • • • • • • • •

Information on the Daily Recommended Intake (DRI) for Energy update Updated information and images for the Nutrition Facts Label Strengthened section on food security/insecurity Updated information on trans fat Expanded section on eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) intake Strengthened section on the top chronic conditions Americans are facing Updated Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) eligibility standards Updated Healthy People 2030 objectives Updated the key elements of the Dietary Guidelines for Americans 2020–2025

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CHAPTER OUTLINE I.

Introduction a. Nutrition is an interdisciplinary science focused on the study of how foods, nutrients, and other food constituents affect health. b. The body of knowledge about nutrition is large and growing rapidly, thus changing views on what constitutes the best nutrition advice. c. This chapter links principles of the science of nutrition with applications that can enhance the public’s nutritional health.

II.

Principles of the Science of Nutrition Understand the meaning of the nutrition concepts presented. (LO 1.1) a. Basic nutrition is discussed in this chapter to provide students with a quick, simple crash course on important nutrition principles. b. The 10 principles of human nutrition, listed in Table 1.1, beginning with “food is a basic need of humans,” constitute the thread that links the many concepts presented in this chapter.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

c. Six major nutrient categories (carbohydrate, protein, fats [lipids], vitamins, minerals, and water) are defined in Table 1.2. d. Dietary intake standards for each of the essential nutrients in the six nutrient categories do not account for an individual’s age, biological sex, growth, and pregnancy and lactation. e. A thorough list of food sources of vitamins is provided in Table 1.10, and a list of food sources of minerals is presented in Table 1.14. f. Examples of diseases and disorders that are linked to diet are given in Table 1.16. III.

Nutrition Labeling Read and understand the elements of nutrition labels; you will be able to understand the nutritional value of most food products. (LO 1.2) a. The Nutrition Facts panel must include the content of fat, saturated fat, trans fat, cholesterol, sodium, total carbohydrates, fiber, sugars, protein, vitamins, calcium, and iron in a standard serving. b. Food products must list ingredients in an ingredient label, and the list must begin with the ingredient that contributes the largest amount of weight to the product. c. Food labels and dietary supplement labels must have an explanation of the health claims on the product, and provide definitions of enrichment and fortification. d. Prebiotics and probiotics are both derived from antibiotics due to their probable effects on increasing resistance to various diseases.

IV.

The Life-Course Approach to Nutrition and Health Cite two examples of how nutrient needs change during the life cycle and how nutritional status at one stage during the life cycle can influence health status during another. (LO 1.3) a. Nutrient needs during each stage of the life cycle can be met through a variety of foods and food practices. b. Traditional diets defined by diverse cultures and religions provide the foundation for meeting individuals’ nutrition needs. c. Cross-cultural adaptations can be made to some extent based on income, food cost, and food availability. d. Being aware of many cultural and religious food practices and beliefs can be very beneficial in nutrition education and counseling situations.

Nutrition Assessment Describe the components of individual-level nutrition assessment. (LO 1.4)

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

a. The extent and thoroughness of a nutrition-related assessment depends on the proposed use of the assessment. b. Questions about nutritional status are asked in the context of planning for prevention or a solution of nutrition-related health problems. c. A community-level assessment generally includes examining existing vital statistics data, seeking the opinions of target group members and local health experts, and making observations. d. Community-level nutrition assessments can be used to develop communitywide programs addressing specific problem areas in the population such as childhood obesity or iron-deficiency anemia. e. Individual assessments are compiled using four major components: (1) clinical/physical assessment, (2) dietary assessment, (3) anthropometric assessment, and (4) biochemical assessment. f. In the clinical setting, computerized 24-hour dietary recalls and food records are most commonly used to assess dietary intake. g. Food availability, dietary intake, weight status, and nutrition-related disease incidence are investigated regularly in the United States by the National Nutrition Monitoring System. h. Several national survey methods are described (Table 1.18). VI.

Public Food and Nutrition Programs Identify the basic elements of four public food and nutrition programs. (LO 1.5) a. A variety of federal, state, and local programs are available to provide food and nutrition services to families and individuals. b. Household eligibility depends on the need, which is defined as including individual and household incomes below the poverty line. c. Food and nutrition programs provide vouchers; cash; or actual food, nutrition services, education, and referral. Table 1.20 provides examples of federal food and nutrition programs that are further described in the life-cycle chapters. d. Table 1.21 provides the objectives for improving the nutritional health of the nation as outlined in the document Healthy People 2030.

VII.

Nutrition and Health Guidelines for Americans Design a healthy dietary pattern. (LO 1.6) a. The Dietary Guidelines for Americans provide science-based recommendations to promote health and to reduce the risk for major chronic diseases through diet and physical activity. b. The 2025 Dietary Guidelines Advisory Committee, which consisted of scientific experts on nutrition and health, concluded that the health of the U.S. population could be improved, and common chronic diseases and disorders prevented, if Americans were to consume a healthy dietary pattern (shown in Table 1.22) and exercise regularly.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

c. Key elements of the 2020–2025 Dietary Guidelines for Americans related to food and nutrient intake, dietary pattern, and food safety and sustainability are listed in Table 1.23. d. ChooseMyPlate.gov (Figure 1.10), the replacement for the former USDA Food Guide Pyramid, offers individual guidance regarding what to eat, including adaptations for various cultural eating patterns. [return to top]

DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class. 1.

In Table 1.1, Principle #3 of the 10 human nutrition principles states: “Health problems related to nutrition originate within cells.” Describe your own personal definition of health. Considering the statement “Health is more than the absence of disease,” identify indicators of health. Can someone who has asthma or diabetes be “healthy”? (L0 1.1)

“Not all fats are created equal.” After years of “eat less fat” advice, we are becoming more vocal about the benefits of fats in the diet. The definition of “healthful” is based on the way a fat/lipid affects LDL cholesterol (healthful fat doesn’t raise, and more likely lowers, LDL cholesterol). Discuss the concept of “healthful” versus “unhealthful” fats. Do you agree with this way of defining healthful? (LO 1.1)

Americans eat roughly nine times as much omega-6 fatty acid as omega-3 fatty acid. While we still do not know an optimal ratio, the suggestion is that eating four times as much omega-3 fatty acid relative to omega-6 fatty acid would promote health. Discuss ideas for reaching this lower and more health-promoting ratio. (LO 1.1)

One of the nutrition objectives of Healthy People 2030 (Table 1.21) is to reduce overweight and obesity by helping people eat healthy food and get physical active. What are some reasonable ways this goal could be accomplished? (LO 1.5)

Principle #9 (p. 35 and Table 1.1 on p. 2) reads, “Adequacy, variety, and balance are key characteristics of healthy dietary patterns.” How does this principle relate to Principle #4 (p. 23 and Table 1.1 on p. 2), which states,

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

“Poor nutrition can result from both inadequate and excessive levels of nutrient intake”? Describe the physiological effects of one nutrient (e.g., calcium) to illustrate how adequacy and balance in dietary intake support a “just-right” range of nutrient needs in humans. (LO 1.1) 6.

Label interpretation practice: Use Table 1.3 and Figure 1.8 (p. 37) showing the mandatory components of a nutrition label and a Nutrition Facts panel. Although Daily Values (DV) are designed for everyone, they include some nutrient values that have since been revised (e.g., iron). The standardized format on the food label can guide food choices. Using actual food product labels as examples, ask students to determine how much of a nutrient several foods contain (e.g., calcium in milk, vitamin C in orange juice [120% in 8 oz], vitamin A in ketchup [6% in 1 Tbsp], fiber in beans]. How might students use this label information in their own diets? To convert this into a class activity, have everyone bring labels to use when looking up nutrients in foods, then have students make a meal or a diet meeting 35% or 100% of DV. Would they themselves eat the combination of foods chosen? (LO 1.2)

Some food sources of fat-soluble vitamins are not considered to be fatty foods, such as carrots, sweet potatoes, and peppers as a source of vitamin A; broccoli as a source of vitamin K; and whole-wheat bread as a source of vitamin E. How can nonfatty foods be good sources of fat-soluble vitamins? [All foods contain some fat, however minute, so vegetables that do not contain enough fat to appear on a food label still contain enough to carry vitamins occurring in micro- and milligram amounts.] (LO 1.1)

Table 1.9 is a summary of vitamins. Choose one that is well known (e.g., vitamin C) to illustrate the consequences of deficiency as well as the consequences of overdose. Reviewing the primary food sources (in Table 1.9) and the additional specific food sources (Table 1.10) of this vitamin, how likely is it for class members to over- or underdose? If the nutrient chosen is used in enrichment or fortification of foods (e.g., vitamin C is added to some WIC-eligible apple juice), is there a potential of overconsumption? Should we treat fortified foods as vitamin/mineral supplements? (LO 1.1)

The author suggests that “enough is as good as a feast” when discussing the concept of optimum ranges of nutrient intake to promote health (nutrition principle #4). Ask students to generate examples to illustrate this concept. (LO 1.1)

10.

The concept of variety and moderation, or in Principle #9, adequacy and balance, is basic to meeting nutritional needs. How might you apply this concept in various cultures? For instance, on page 39, food intake for someone from El Salvador might include corn tortillas for breakfast, lunch,

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

and/or dinner. Why do nutritionists use the concept of variety in giving dietary advice? (LO 1.3)

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ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. “Find a Person Who” Introduction Activity for the Classroom (LO 1.1) Total Time: 15 minutes Objective: Enhancing emotional classroom environment. Class size: All sizes. Materials needed: Copy of form described below (developed by instructor) for each student. Instructions: Students sometimes enjoy classes more when they are acquainted with other students. One way to assist this process is by providing students with a “Find a Person Who” form. Develop a form several columns wide and several rows long that lists a variety of traits in each square such as enjoys cooking, recycles, has a pet, and is a nutrition major. Instruct students to walk around the class, introduce themselves to each other, and try to find a person who fits the categories described on the sheet. When they find someone who fits a category, have them write the person’s first name in that category. The goal is to complete the sheet. You may also suggest that they exchange e-mail addresses or phone numbers and form study groups. This activity works best for small to medium-sized classes.

2. Class Debate: The 10th Principle of Human Nutrition (Table 1.1, and p. 36) states that “there are no ‘good’ or ‘bad’ foods.” (LO 1.1) Total Time: Will vary per group a. Split the class in half by having them move to one or the other side of the room. Assign one side the position that “identifying good and bad foods can help the consumer choose a healthful diet” and assign Principle #10 to the other side. Have each side form small groups of 2–4 and prepare arguments for their position, writing their summaries on note cards. After roughly 5 (no more than 10) minutes of deliberation, have each side of the room self-select a team to present their position. Have the rest of the students help shape that position with additional points generated in the small groups. b. After the representative teams are selected, the rest of the students go back to their seats and become the audience. Pro and con sides then have 2–3 minutes each to make their case; add rebuttals if time allows. c. Facilitate (instructor-led) a debriefing involving the audience and the presenting teams, which stay where they are. Sample debriefing questions are “What does it mean to eat food occasionally?” “Why is the term junk food so

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

useful, or is it?” Can they think of other terms for junk food such as emptycalorie food? Summarize the debate by asking if they agree with Principle #10. 3. Complete Worksheet 1-1: Case Study—Cultural Considerations in Menu Planning (LO 1.5) Total Time: 20–30 minutes Answer Key: Answers will vary. 4. Complete Worksheet 1-2: Calculating Calories (LO1.2) Total Time: 15 minutes Answer Key: 1. 18 calories 2. 112 calories 3. 20 calories 4. 150 calories 5. 3.08% DV of fat 6. 9.33% DV of carbohydrate 5. Complete Worksheet 1-3: Influences on Food Choices Classroom/Online Worksheet (LO 1.4) Total Time: 20–30 minutes Answer Key: Answers will vary.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

Worksheet 1-1: Case Study—Cultural Considerations in Menu Planning (LO 1.5) You are the new registered dietitian at a hospital that serves many clients of Middle Eastern descent. In the past, you have used sample 2000-calorie menus from ChooseMyPlate.gov in patient education sessions to demonstrate how to plan healthy meals. You find that you need to modify these menus to better suit your clientele’s preferences. 1. Search the Internet for resources that describe Middle Eastern food practices. One example can be found at the Ohio State University Extension website: http://ohioline.osu.edu/hyg-fact/5000/pdf/5256.pdf 2. Using your selected resources as a guide, modify the menu listed below to better meet your clientele’s food preferences. Current Menu Breakfast Cold cereal: 1 cup shredded wheat cereal 1 Tbsp raisins 1 cup fat-free milk 1 small banana 1 slice whole-wheat toast 1 tsp soft margarine 1 tsp jelly

Recommended Changes

Lunch Smoked turkey sandwich: 2 ounces whole-wheat pita bread ¼ cup romaine lettuce 2 slices tomatoes 3 ounces sliced smoked turkey breast 1 Tbsp mayo-type salad dressing 1 tsp yellow mustard ½ cup apple juice 1 cup tomato juice Dinner 5 ounces grilled top loin steak ¾ cup mashed potatoes 2 tsp soft margarine ½ cup steamed carrots 1 Tbsp honey 2 ounces whole-wheat dinner roll 1 tsp soft margarine 1 cup fat-free milk Snacks 1 cup low-fat fruited yogurt

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

Worksheet 1-2: Calculating Calories (LO 1.2) Directions: Use the information from the nutrition label below to determine the total calories as well as the calories from protein, carbohydrate, and fat for 1 muffin. Once you have calculated the calories from protein, carbohydrate, and fat, and the % DV for fat and carbohydrate, fill in the blanks on the nutrition label. Nutrition Facts: Serving Size 1 Muffin (57 g) Serving per container 6 Calories _________

Calories from fat __________

Amount/Serving Total Fat 2g Saturated 0g Cholesterol 0 g Sodium 240 mg

Vitamin A Thiamin

0% 15%

% DV* ________ 0% 0% 10%

Vitamin C Riboflavin

0% 4%

Amount/Serving Total Carbohydrate 28 g Dietary Fiber 3g Sugars 2g Protein 5g

% DV _________ 11%

Calcium Niacin

6% 10%

Iron

1. What are the total calories from fat? 2. What are the total calories from carbohydrate? 3. What are the total calories from protein? 4. What are the total calories from each muffin? 5. What is the % daily value of total fat? 6. What is the % daily value of total carbohydrate? *Percent Daily values (DV) are based upon a 2000-calorie diet. The Daily value for fat for a 2000-calorie diet: 65 g The Daily value for carbohydrate is: 300 g

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

Worksheet 1-3: Influences on Food Choices Classroom/Online Worksheet (LO 1.4) We decide what to eat, when to eat, and even whether to eat for a variety of reasons. Examine the factors that influence your food choices by keeping a food diary for 24 hours. Record the times and places of meals and snacks, the types and amounts of foods eaten, and a description of your thoughts and feelings when eating. Then examine your food record and consider your choices. 24-Hour Food Diary Meal

Breakfast

Time/Place Food Items

How Much

How Do You Feel While Eating?

Do You Feel This Was a Good Meal?

Grains Fruits Dairy Protein Fat

Snack Lunch

Grains Fruits Dairy Vegetables Protein Fat

Snack Dinner

Grains Fruits Dairy Vegetables Protein Fat

Snack

1. Which, if any, of your food choices were influenced by emotions (happiness, boredom, or disappointment, for example)?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

2. Was social pressure a factor in any food decisions?

3. Which, if any, of your food choices were influenced by marketing strategies or food advertisements?

4. How large a role does availability, convenience, and economy play in your food choices?

5. Does your age, ethnicity, or health influence your food choices?

6. How many times did you eat because you were truly hungry? How often did you think of health and nutrition when making food choices? Were those food choices different from others you made during the day?

Compare the choices you made in your 24-hour food diary to the USDA MyPlate Food Plan Recommendation. To obtain a set of personalized recommendations, enter your age, sex, height, weight, and activity level after clicking on “Get Your My Plate Plan” at the https://www.choosemyplate.gov/resources/MyPlatePlan Food Groups Grains Vegetables Fruits Dairy Protein

Suggested Amounts

Amounts Consumed

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

7. Do you eat the suggested amounts from each of the five food groups daily?

8. Do you try to vary your choices within each food group from day to day?

9. What dietary changes could you make to improve your chances of enjoying good health?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

ADDITIONAL RESOURCES INTERNET RESOURCES ●

Mercury levels in commercial fish and shellfish o

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Nutritional labeling o

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USDA MyPlate: http://www.choosemyplate.gov/

DASH eating plan: http://health.gov/dietaryguidelines/dga2005/document/pdf/Appendix_ A.pdf

Public nutrition programs

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National Health and Nutrition Examination Survey: http://www.cdc.gov/nchs/nhanes/htm

Nutrition and health guides o

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What’s in the Foods You Eat: http://www.ars.usda.gov/Services/docs.htm?docid=17032

National Nutrition Monitoring System o

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Nutrition.gov: http://www.nutrition.gov

Dietary assessment o

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Information on existing federal food and nutrition programs from the USDA Food and Nutrition Service: http://www.fns.usda.gov/

Nutrition and health guidelines

o ●

U.S. Food and Drug Administration (FDA) information on Nutrition Facts Panels: http://www.fda.gov/downloads/Food/GuidanceDocumentsRegulatoryIn formation/LabelingNutrition/.pdf

Public food and nutrition programs o

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U.S. Environmental Protection Agency: http://www.epa.gov

Eating Well with Canada’s Food Guide: http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php

Nutrition experts o

Academy of Nutrition and Dietetics: http://www.eatright.org

Dietitians of Canada: http://www.dietitians.ca

Nutrition research

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 1: Nutrition Basics

o ●

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Medline Plus: http://www.nlm.nih.gov/medlineplus

Nationwide priorities and nutritional health o

United States: healthy people 2030 Objectives for the Nation: http://www.healthypeople.gov/2030/topicsobjectives2030/default.asp x

Canada: Health Canada: http://www.hc-sc.gc.ca

Governmental sites reflecting current food and nutrition information o

The National Agricultural Library at USDA: http://www.nal.usda.gov/

The Institute of Medicine: http://iom.nationalacademies.org/

The National Academy of Sciences Tables for DRIs: http://ods.od.nih.gov/Health_Information/Dietary_Reference_Intakes.as px

The U.S. Department of Health and Human Services publishes poverty statistics at http://aspe.hhs.gov/poverty/index.shtml

Canada’s Food Guide: http://www.hc-sc.gc.ca/fn-an/food-guidealiment/index-eng/php

A census site for locating your own community and finding poverty statistics in general is at http://www.census.gov/library/publications/2018/demo/p60-263.html

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 2: Preconception Nutrition

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 2: PRECONCEPTION NUTRITION

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 5 Chapter Outline ................................................................................................................... 5 Discussion Questions.......................................................................................................... 8 Additional Activities and Assignments ............................................................................ 10 Additional Resources .........................................................................................................13 Internet Resources.................................................................................................................. 13

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to address the role of nutrition in specific conditions— such as eating disorders, premenstrual syndrome, obesity, diabetes, polycystic ovary syndrome, and celiac disease—that affect preconceptional health and fertility. Preconceptional nutritional status influences maternal health and the course and outcome of pregnancy. Preconception health services should be a part of primary health care and would likely improve fertility and pregnancy outcomes.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 2.1

Cite three examples of the Healthy People 2030 nutrition-related objectives for the preconception period.

2.2

Identify six major hormones involved in the regulation of male and female fertility processes and identify their source and effects on the regulation of fertility processes.

2.3

Describe the potential effects of nutrition-related factors such as body fat content, iron status, and alcohol intake on fertility in women and men.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 2: Preconception Nutrition

2.4

Cite four examples of relationships between nutrient intake and nutritional status during the periconceptional period and the outcome of pregnancy.

2.5

Develop a one-day menu for preconceptional individuals based on the MyPlate.gov food guidance materials.

2.6

Identify three nutrition-related consequences that may be related to the use of combination hormonal contraceptives, and a consequence that is related to the use of estrogen and progestin contraceptives only.

2.7

Cite three important nutrition-related components of preconceptional health care.

2.8

Describe the four steps of the Nutrition Care Process.

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KEY TERMS Infertility: Involuntary absence of production of children. Infecundity: Biological inability to bear children after one year of unprotected intercourse. Fertility: Actual production of children. The word best applies to specific vital statistic rates, but it is commonly taken to mean the ability to bear children. Fecundity: Biological ability to bear children. Miscarriage: Generally defined as the loss of a conceptus in the first 20 weeks of pregnancy. Also called spontaneous abortion. Fetus: The developing organism from eight weeks after conception to the moment of birth. Endocrine: A system of ductless glands, such as the thyroid, adrenal glands, ovaries, and testes, that produces secretions that affect body functions. Immunological: Having to do with the immune system and its functions in protecting the body from bacterial, viral, fungal, or other infections and from foreign proteins (i.e., those proteins that differ from proteins normally found in the body). Subfertility: Reduced level of fertility characterized by unusually long time to conception (over 12 months) or repeated pregnancy losses. Puberty: The period in life during which humans become biologically capable of reproduction.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 2: Preconception Nutrition

Ova: Eggs of the female produced and stored within the ovaries (singular is ovum). Menopause: Cessation of the menstrual cycle and reproductive capacity in women. Menstrual cycle: An approximately 4-week interval in which hormones direct a buildup of blood and nutrient stores within the wall of the uterus and ovum maturation and release. If the ovum is fertilized by a sperm, the stored blood and nutrients are used to support the growth of the fertilized ovum. If fertilization does not occur, they are released from the uterine wall over a period of 3 to 7 days. The period of blood flow is called the menses, or the menstrual period. Hypothalamus: A section of the brain responsible for the production of many hormones and other chemical substances that affect body functions such as temperature regulation, thirst, hunger, sleep, mood, reproduction, and the release of other hormones within the body. Pituitary gland: A pea-sized gland located at the base of the brain. It is connected to the hypothalamus and produces and secretes growth hormone, prolactin, oxytocin, follicle-stimulating hormone, luteinizing hormone, and other hormones in response to signals from the hypothalamus. Corpus luteum: (corpus= body, luteum= yellow) A tissue about 12 mm in diameter formed from the follicle that contained the ovum prior to its release. It produces estrogen and progesterone. The “yellow body” derivation comes from the accumulation of lipid precursors of these hormones in the corpus luteum. Prostaglandins: A group of physiologically active substances derived from the essential fatty acids. They are present in many tissues and perform such functions as the constriction or dilation of blood vessels and stimulation of smooth muscles and the uterus. Testes: Male reproductive glands located in the scrotum. Also called testicles. Androgens: Types of steroid hormones produced in the testes, ovaries, and adrenal cortex from cholesterol. Some androgens (testosterone, dihydrotestosterone) stimulate development and functioning of male sex organs. Sertoli cells: Cells in the testes that secrete substances that nourish and support the maturation of immature sperm cells. Epididymis: Tissues on top of the testes that store sperm. Semen: The penile ejaculate containing a mixture of sperm and secretions from the testes, prostate, and other glands. It is rich in zinc, fructose, and other nutrients. Also called seminal fluid. Pelvic inflammatory disease (PID): A general term applied to infections of the cervix, uterus, fallopian tubes or ovaries. Occurs predominantly in women who are less than

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 2: Preconception Nutrition

25 years of age and is generally caused by infection with a sexually transmitted disease, such as gonorrhea or chlamydia. Endometriosis: A disease characterized by the presence of endometrial tissue in abnormal locations, such as deep within the uterine wall, in the ovary, or in other sites within the body. The condition is quite painful and associated with abnormal menstrual cycles and infertility in 30 to 40 percent of affected women. Leptin: A protein secreted by fat cells that, by binding to specific receptor sites in the hypothalamus, decreases appetite, increases energy expenditure, and stimulates gonadotropin secretion. Leptin levels are elevated by high, and reduced by low, levels of body fat. Body mass index (BMI): Weight in kg/height in m2. BMIs <18.5 are considered underweight, 18.5–24.9 healthy weight, 25–29.9 overweight, and BMIs of 30 and higher obesity. Anovulatory cycles: Menstrual cycles in which ovulation does not occur. Amenorrhea: Absence of menstrual cycle. Functional hypothalamic amenorrhea (FHA): A non-organic (not due to disease) and reversible disorder in the hypothalamus that impairs gonadotropin-releasing hormone (GnRH) pulsatile secretion and suspends ovulation and menstrual cycles. Antioxidants: Chemical substances that prevent or repair damage to molecules and cells caused by oxidizing agents. Vitamins C (see Photo 2.1) and E, selenium, and certain components of plants function as antioxidants. Free radicals: Chemical substances (often oxygen-based) that are missing electrons. The absence of electrons makes the chemical substance reactive and prone to oxidizing nearby molecules by stealing electrons from them. Free radicals can damage lipids, cell membranes, DNA, and tissues by altering their chemical structure and functions. They also form as a normal part of metabolism. Over time, oxidative stress causes damage to lipids, cell membranes, DNA, cells, and tissues. Periconceptional Period: The time period around conception, variously measured in weeks or months depending on the pregnancy outcomes of interest. Embryo: The developing organism from conception through eight weeks. DNA methylation: The modification of a replicated strand of DNA by addition of a methyl group (CH3) to specific regions of the strand. Methylation can suppress the activity of certain genes in ways that affect metabolic processes and disease risk. It is a normal part of development and is needed for cellular differentiation and organ development but can also be influenced by nutritional and other environmental exposures.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 2: Preconception Nutrition

Neural tube defects (NTDs): A group of birth defects that are caused by incomplete development of the brain, spinal cord, or their protective coverings. Spina bifida is one of the most common types of neural tube defects. Small for gestational age (SGA): Newborn weight is less than 10th percentile for gestational age. Also called small for date (SFD). Dietary folate equivalents (DFE): A measure of folate availability used by the Reference Dietary Intakes. 1 DFE = 1 mcg food folate, which is equivalent to 0.6 mcg folic acid. Allele: A different version of the same gene. Alleles have a different arrangement of bases than the usual version of the gene. Gene variant: An alteration in the normal sequence of a gene. The different forms of the same genes are considered alleles. [return to top]

WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • •

Updated data and statistics throughout the chapter Revised folic acid supplementation levels in fortified cereals Updated Healthy People 2030 objectives related to pregnancy and childbirth

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CHAPTER OUTLINE I.

Introduction a. The reproductive processes will be discussed in this chapter, and students with biology, anatomy, and physiology expertise will have an edge over those who are less familiar with these reproductive terms. b. The chapter will focus on the effects of nutrition on fertility and provide an overview of the Nutrition Care Process used for individuals before pregnancy and for others.

II.

Preconception Overview Cite three examples of the Healthy People 2030 nutrition-related objectives for the preconception period. (LO 2.1)

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 2: Preconception Nutrition

a. Fertility (actual production of children, typically as rate or number of children born per 1000 women aged 15-44) and fecundity (the biological capacity to bear children) are differentiated in this chapter. b. The common meaning of infertility (biological inability to bear children) is used throughout the chapter. c. Regular, unprotected intercourse leads to a 25–30% chance of pregnancy within one menstrual cycle in healthy couples; however, 30–50% of conceptions do not continue to develop to the fetal stage due to resorption into the uterine wall or miscarriage in the first 20 weeks of pregnancy. d. An important concept emphasized by Table 2.1, listing Healthy People 2030 nutrition objectives, is that goals for preconceptional health apply to men and to women. III.

Reproductive Physiology Identify six major hormones involved in the regulation of male and female fertility processes and identify their source and effects on the regulation of fertility processes. (LO 2.2) a. Section highlights are presented in Illustrations 2.1 and 2.2. b. Females are born with a full set of ova that are used up by menopause, whereas males are born with sperm-producing capabilities that last throughout the life span. c. The rise and fall of estrogen and progesterone levels affect menstrual cycles in women; in males, reproduction is an ongoing rather than a cyclic process. d. Testosterone stimulates the maturation of sperm, which takes 70–80 days. Table 2.2 provides an overview of hormones that affect reproduction. e. Endocrine abnormalities and “unknown causes” are the leading infertility diagnoses. f. Infertility risk factors are summarized in Table 2.3.

IV.

Nutrition and Fertility Describe the potential effects of nutrition-related factors such as body fat content, iron status, and alcohol intake on fertility in women and men. (LO 2.3) a. Undernutrition can be chronic or long term and is associated with delivery of small, frail infants with a high likelihood of death in the first year. b. There is a 10-fold infant death rate difference between poor and developed countries, although studying chronic undernutrition is complicated by factors such as varying contraceptive practices, ages of puberty and marriage, and breastfeeding duration. c. Acute undernutrition is related to lower birthrates. Examples of acute undernutrition are famine and food shortages due to war, crop failures, and poor hunting conditions. d. Births increase after the food shortage is resolved, but it can take up to a year for menstrual cycles to return to normal.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 2: Preconception Nutrition

e. Other factors affecting fertility are discussed: body fat, weight loss, exercise, certain dietary patterns such as vegetarianism, preconception iron status, and high caffeine and alcohol intakes. f. Nutritional factors affecting male fertility include weight loss of 10–15% below normal, low zinc status, lack of antioxidant nutrients, high level of alcohol intake, and exposure to heavy metals. V.

Nutrition During the Periconceptional Period Cite four examples of relationships between nutrient intake and nutritional status during the periconceptional period and the outcome of pregnancy. (LO 2.4) a. Table 2.6 details periconceptional nutritional exposures that may affect the growth and development of the embryo and fetus. b. Insufficient maternal folate stores may increase the baby’s risk of neural tube defects as well as other physical defects. c. Low iron stores have been shown to increase the baby’s risk of being delivered prematurely and having low iron stores.

VI.

Recommended Dietary Intake and Healthy Dietary Patterns for Preconceptional Women Develop a one-day menu for preconceptional individuals based on the MyPlate.gov food guidance materials. (LO 2.5) a. Nutritionally balanced meals for preconceptional women can be designed with the help of the USDA’s ChooseMyPlate.gov dietary planning tools. Examples of such meal plans are summarized in Table 2.8 and Table 2.9.

VII.

Influence of Contraceptives on Preconceptional Nutrition Status Identify three nutrition-related consequences that may be related to the use of combination hormonal contraceptives, and a consequence that is related to the use of estrogen or progestin contraceptives only. (LO 2.6) a. Hormonal contraceptives have implications for the human body; some contraceptives (like Depo-Provera) are associated with weight gain, whereas other contraception methods can alter blood lipid levels and glucose metabolism. b. Hormonal contraception for males exists but is not currently available because it still needs to be approved.

VIII.

Model Preconceptional Health and Nutrition Programs Cite three important nutrition-related components of preconceptional health care. (LO 2.7) a. WIC is a USDA program designed to improve reproductive health. b. A program to decrease iron deficiency in Indonesia is an international example of improving preconception nutrition.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 2: Preconception Nutrition

c. “Starting pregnancy in the best health status possible can make an important difference to reproductive outcomes,” but it is not a guarantee for a perfect newborn. IX.

The Nutrition Care Process Describe the four steps of the Nutrition Care Process. (LO 2.8) a. The Nutrition Care Process is a standard nutrition care methodology developed by the Academy of Nutrition and Dietetics to serve as a guideline for the delivery of nutrition services (Table 2.10 summarizes the components of the Nutrition Care Process). b. Preconception services are tailored to the nutrition needs of women before pregnancy, and to the nutrition and reproductive health needs of men. [return to top]

DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class. 1. Distinguish between fecundity (biological capacity to bear children), infertility (lack of conception after one year of unprotected intercourse), and being subfertile. (LO 2.1) a. Discuss the main reasons for often-delayed conception in 18% of married couples in the United States. b. Identify what helps and harms men and women who wish to have children; describe practices that support robust pregnancy outcomes. How can a comparison of reproductive health practices and outcomes among communities and nations be used to understand conceptional health? [Spot problems, identify trends, and prevent poor outcomes.] 2. What makes nutritional aspects of reproduction different for males and females? Have students elaborate on any or all of the following statements: (LO 2.2) a. Hormones differ between males and females. b. Body composition, that is, percent body fat, differs between males and females. c. Women carry the developing fetus through gestation, whereas males do not. d. Women are born with a full complement of eggs that run out around menopause, whereas men can produce sperm indefinitely, even if the number or viability of sperm declines.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 2: Preconception Nutrition

3. What are the relationships between body weight and conception? Discuss the national health goals found in Healthy People 2030 (Table 2.1) as they affect conception. (LO 2.3) a. Define a healthy weight range, using body mass index (found inside text cover). Would BMI change in a woman who was in her late 40s and planning on becoming pregnant? That is, does age affect our perception of what a healthy weight range is? Why or why not? b. Definitions of what constitutes a healthy weight vary. BMI is not a strong enough measure to yield consistent interpretations about optimal weight, although the NIH has published national guidelines. Unlike the atomic clock, to which people around the world calibrate their computers and watches, BMI is meant to be used as a general guide; in this case, for conception and optimal pregnancy outcome. c. Healthy weight is also a cultural issue. Perceptions of beauty and desirable body shape vary from culture to culture. A country or community where many people with various cultural backgrounds live has a more difficult time developing relevant population guidelines regarding a “healthy weight.” d. Obesity and underweight both decrease ability to conceive (Table 2.3). Weight loss of more than 10–15% of normal weight is related to infertility in men and women. To explain what 15% of normal weight means, point out that a 100pound person would now weigh 85 pounds, and a 150-pound person would now weigh 122.5 pounds (a decrease of several clothing sizes). e. Weight-related factors that impact fertility are summarized in Table 2.3, including negative energy balance, too little body fat, excessive body fat, anorexia nervosa, and bulimia nervosa. Pages 56–57 suggest that fertility is compromised when BMI is less than 20 and more than 30. f. Summary: Evidence relating weight status to preconception nutrition suggests that a fairly broad range of body weights will support pregnancy. 4. Why is it recommended that females who are at risk of cardiovascular disease or blood clots as well as women with high blood pressure use nonhormonal methods of contraception? (LO 2.6) 5. High levels of body fat lead to increased levels of leptin and estrogen; low levels of body fat decrease leptin and estrogen. How do these high or low hormone levels affect fertility? (LO 2.3) 6. Estrogen and progesterone prompt the endometrium to store glycogen and other nutrients during both the follicular and the luteal phases. Does this nutrient-storage function of estrogen and progesterone support fertility or fecundity? Elaborate. (LO 2.2) [return to top]

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 2: Preconception Nutrition

ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. Pick One of the Pharmaceutical or Drug Contraceptive Methods and Develop Nutritional Advice for Women Using That Method (LO 2.6) Total Time: 30 minutes You are a consulting nutritionist with Women’s Health Clinic and are asked to develop nutrition-focused take-home literature to be used with oral contraceptives, contraceptive injections, implants, and mechanical devices (e.g., diaphragm). Pick one of the pharmaceutical or drug methods and develop nutritional advice for women using that contraceptive method. Compare this advice to what you would tell someone who is using a diaphragm. Be sure to include advice on foods to eat, such as a sample meal plan or food lists. (Refer to Tables 2.6, 2.7, 2.8, and 2.9 or ChooseMyPlate.gov; see also heart disease prevention in Chapter 17.) 2. Develop a “Healthy Sperm Diet” (LO 2.3) Total Time: 40 minutes Develop a Healthy Sperm Diet for use by the health clinic on campus. Be sure to include some of the fast foods available on or near your campus. [Text, beginning on page 58, addresses adequate zinc, high level of antioxidants, light to moderate alcohol, clean arteries, controlled diabetes, seafood, and avoidance of heavy metals such as mercury.] 3. Women, Infants, and Children (WIC) Program Classroom/Online Activity (LO 2.7) Total Time: 25 minutes Have the students visit the Women, Infants, and Children (WIC) program website and create a research paper on the most important micronutrients required in the diets of pregnant and lactating mothers.

4. Multipart Questions (LO 2.3) Total Time: will vary (this one requires homework) Before discussion, assign students an online search: a. What can each one find out about the effectiveness of the herb black cohosh in treating menstrual disorders? Is the information they found referenced? What are the references used? Are any of the sites used linked to product sales? If so, give examples. How would a consumer know which advice can be trusted? b. Compile student answers (whiteboard, overheads) and discuss: i. How did they devise a search strategy? ii. Review their findings, using each of the questions in their assignment. c. Summarize: If students were asked for advice regarding cohosh from their best friend, what would they suggest? What would you (their instructor) advise? What were the most credible online resources? Where could they go to verify information? d. How can the class apply this process to other herbal or new products? 5. Complete Worksheet 2-1: Preconception Nutrition Counseling (LO 2.5) Total Time: 20 minutes

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 2: Preconception Nutrition

Answers: 1. Oral contraceptives might cause increased blood levels of triglycerides and LDL cholesterol (p. 64). Considering her family history of heart disease and type 2 diabetes, and the absence of current lab work, it would be prudent to recommend she see her health care provider to have current lipids and glucose labs drawn. Based on the results of these labs, she may want to discuss alternative forms of contraception with her provider, including changing the type of oral contraceptive. 2. BMI = 28.2 isn’t associated with compromised fertility; history of iron-deficiency anemia could interfere with fertility, so she should have current iron levels checked; caffeine intake is excessive and may interfere with fertility. 3. Continue and/or increase current level of physical activity, decrease caffeine intake, have annual physicals (including lab work), and follow an individualized meal plan according to the USDA Food Patterns (available via the ChooseMyPlate.gov website).

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 2: Preconception Nutrition

Worksheet 2-1: Preconception Nutrition Counseling (LO 2.5) Catherine decided to see a registered dietitian after watching a news story about the 2006 CDC Preconception Health Initiative (p. 65), including the recommendation that each person should make a reproductive life plan. Currently 29 years old, she has been on oral contraceptives for 10 years. She would like to have children someday, possibly in her mid-30s, after she has established her career. Her height is 5 feet 6 inches, and her weight is 175 lb. She considers herself fairly active, exercising for about 30 minutes three times per week. Due to being a busy professional, she admits to drinking close to 40 ounces of coffee most days and only occasionally drinks alcohol. Her personal health history includes iron-deficiency anemia at age 25, although she thinks this has resolved; her family history includes heart disease and type 2 diabetes; both of her parents are still living. No recent lab work is available. Her questions for the dietitian are: 1. Should she change her method of contraception for nutrition or other health reasons?

2. Are there any risk factors for impaired fertility in her current health status?

3. What recommendations do you have to help her meet her long-term goal of having children someday?

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 2: Preconception Nutrition

ADDITIONAL RESOURCES INTERNET RESOURCES •

Preconception nutrition o Medscape Ob/Gyn & Women’s Health: http://www.medscape.com/womenshealth o

Women’s Health: http://www.womenshealth.gov/

The BabyCenter Company: http://www.babycenter.com

Academy of Nutrition and Dietetics: http://www.eatright.org/health/pregnancy/fertility-and-reproduction

•

Public food & nutrition programs o

•

WIC: http://www.fns.usda.gov/wic/

Nationwide priorities & nutritional health o

Centers for Disease Control/National Center for Health Statistics: http://www.cdc.gov/nchs

•

Science of nutrition o

Merck Manual of Diagnosis and Therapy: http://www.merckmanuals.com/professional/index.html

National Library of Medicine (PubMed): http://www.ncbi.nlm.nih.gov/pubmed

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 3: preconception Nutrition: Conditions and Interventions

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 3: PRECONCEPTION NUTRITION: CONDITIONS AND INTERVENTIONS

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 4 Chapter Outline ................................................................................................................... 4 Discussion Questions.......................................................................................................... 6 Additional Activities and Assignments .............................................................................. 8 Additional Resources .........................................................................................................13 Internet Resources.................................................................................................................. 13

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to address the roles of dietary intake and energy balance, weight status, eating disorders, diabetes, polycystic ovary syndrome, and other conditions related to nutrition on fertility and the course and outcome of pregnancy.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 3.1

Compare the primary mechanisms that underlie the effects of obesity and underweight on fertility in women and men.

3.2

Identify two mechanisms by which a negative energy balance can influence fertility.

3.3

Illustrate two ways in which good blood glucose control during the periconceptional period can benefit fetal growth and development.

3.4

Cite three key components of the nutritional management of polycystic ovary syndrome (PCOS).

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 3: preconception Nutrition: Conditions and Interventions

3.5

Summarize the major reasons why dietary control of phenylketonuria (PKU) is particularly important prior to pregnancy.

3.6

Describe three nutritional consequences of untreated celiac disease.

3.7

Identify four common symptoms of premenstrual syndrome and the proposed effects of dietary supplements on the symptoms of premenstrual dysphoric disorder (PMDD).

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KEY TERMS Intra-abdominal fat: Fat located within the abdominal cavity around organs such as the liver, pancreas, and intestines. Intra-abdominal fat is referred to as visceral fat and is much more metabolically active than fat stored in other parts of the body. Metabolic syndrome: A constellation of metabolic abnormalities that increase the risk of heart disease, hypertension, type 2 diabetes, and other disorders. Metabolic syndrome is characterized by insulin resistance, abdominal obesity, high blood pressure and triglyceride levels, low levels of HDL cholesterol, and impaired glucose tolerance. It is also called insulin resistance syndrome. Sex hormone binding globulin (SHBG): A protein that binds with the sex hormones testosterone and estrogen. These hormones are inactive when bound to SHBG, but are available for use when needed. Low levels of SHBG are related to increased availability of testosterone and estrogen in the body. Anovulation: The absence of ovulation. Luteinizing hormone (LH): A hormone produced by the pituitary gland that stimulates ovulation, the development of the corpus luteum (which secretes progesterone), and the production of testosterone in men. Follicle stimulating hormone (FSH): A hormone produced by the pituitary gland that stimulates ovarian follicle growth and maturation, estrogen secretion, and endometrial changes characteristic of the first portion of the menstrual cycle in women. It stimulates sperm production in men. Gonadotropin releasing hormone (GnRH): A hormone produced in the hypothalamus that is responsible for the release of follicle stimulating hormone and luteinizing hormone by the pituitary gland. Anorexia nervosa: An eating disorder characterized by extreme weight loss, poor body image, and irrational fears of weight gain and obesity.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 3: preconception Nutrition: Conditions and Interventions

Bulimia nervosa: An eating disorder characterized by recurrent episodes of rapid, uncontrolled eating of large amounts of food in a short period of time. Episodes of binge eating are followed by compensatory behaviors such as self-induced vomiting, dieting, excessive exercise, or misuse of laxatives to prevent weight gain. Autoimmune disease: Diseases that result from a failure of an organism to recognize its own constituent parts as “self.” The organism attempts to defend itself from the perceived foreign substance through actions of its immune system. These actions can damage molecules, cells, tissues, and organs. Type 1 diabetes, lupus and rheumatoid arthritis are examples of autoimmune diseases. Teratogenic: Exposures that produce malformations in embryos or fetuses. Congenital abnormality: A structural, functional, or metabolic abnormality present at birth. Also called congenital anomalies. These may be caused by environmental or genetic factors, or by a combination of the two. Structural abnormalities are generally referred to as congenital malformations, and metabolic abnormalities as inborn errors of metabolism. Type 1 diabetes: A disease characterized by high blood glucose levels resulting from destruction of the insulin-producing cells of the pancreas. This type of diabetes was called juvenile-onset diabetes and insulin-dependent diabetes in the past, and its official name is type 1 diabetes mellitus. Type 2 diabetes: A disease characterized by high blood glucose levels due to the body’s inability to use insulin normally, or to produce enough insulin. This type of diabetes was called adult-onset diabetes and non-insulin-dependent diabetes in the past. Its official name is type 2 diabetes mellitus. Polycystic ovary syndrome (PCOS): (polycysts = many cysts; i.e., abnormal sacs with membranous linings). A disorder primarily characterized by androgen excess (particularly testosterone), polycystic ovaries, and ovulatory dysfunction. Phenylketonuria (PKU): An inherited error in phenylalanine metabolism most commonly caused by a deficiency of phenylalanine hydroxylase, which converts the essential amino acid phenylalanine to the nonessential amino acid tyrosine. Also called hyperphenylalaninemia. Premenstrual syndrome: (premenstrual = the period of time preceding menstrual bleeding; syndrome = a constellation of symptoms). A condition occurring among women of reproductive age that includes a group of physical and psychological symptoms with onset in the luteal phase and subsiding with menstrual bleeding. Premenstrual dysphoric disorder (PMDD) is a severe form of PMS. Luteal phase: The second half of the menstrual cycle (usually days 14–28) that occurs after ovulation.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 3: preconception Nutrition: Conditions and Interventions

Premenstrual dysphoric disorder (PMDD): A severe form of PMS characterized by disabling irritability, sadness, anxiety, depression, and various other symptoms. It begins during the luteal phase of the menstrual cycle and ends with menstrual bleeding.

WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • • • • • • •

Updated data and prevalence of metabolic syndrome Expanded section on metabolic healthy individuals Strengthened section on gestational diabetes Updated gluten-free section, including requirements for the nutrition facts label Provided new gluten-free label Updated prevalence of weight criteria, including underweight, normal weight, overweight, and obesity Added section on dysgeusia, including a definition Expanded section on surrogate pregnancy and increased risk factors in this population

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CHAPTER OUTLINE I.

Introduction a. Ten nutrition-related conditions affecting women before conception are covered in Chapter 3; corresponding interventions to promote conception and healthy pregnancy outcomes are discussed. b. Learning the margin terms and definitions can help students to describe and categorize these conditions.

II. Weight Status and Fertility Compare the primary mechanisms that underlie the effects of obesity and underweight on fertility in women and men. (LO 3.1) a. Excessive body fat, especially when centrally located (a waist circumference of 35 inches or more in women) can decrease fertility. b. Insulin resistance is especially problematic due to its stimulation of testosterone production. c. Weight loss in obese males and females has been linked to increasing fertility and is considered the first therapeutic option for infertility in obese men and women.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 3: preconception Nutrition: Conditions and Interventions

d. The role of nutrition therapy in metabolic syndrome is discussed. III. Underweight and Fertility Identify two mechanisms by which a negative energy balance can influence fertility. (LO 3.2) a. Pregnant women suffering from eating disorders like anorexia nervosa and bulimia nervosa are more likely to experience complications such as miscarriage or preterm delivery. b. Menstrual irregularities are related to hormonal changes, especially to release of GnRH (Table 2.2 in chapter 2) and to low levels of estrogen. c. Weight gain is typically associated with the return of menses, but infertility may persist. d. The role of nutrition therapy in hypothalamic amenorrhea and the female athlete triad are addressed. Both disorders require increased caloric intake. IV. Diabetes Prior to Pregnancy Illustrate two ways in which good blood glucose control during the periconceptional period can benefit fetal growth and development. (LO 3.3) a. The interrelationship among diabetes, blood glucose control, insulin resistance, and overweight is complex. b. Elevated blood glucose during early pregnancy is associated with higher rates of miscarriage and a two- to threefold increase in congenital abnormalities. c. For overweight and obese women with diabetes or insulin resistance, the tight glucose control that supports fetal development is improved after weight loss. d. The detrimental effects of poor glucose control make diabetes an especially important periconceptional concern, and this section describes relevant dietary aspects, including the glycemic index. V. Polycystic Ovary Syndrome and Fertility Cite three key components of the nutritional management of polycystic ovary syndrome (PCOS). (LO 3.4) a. This complex syndrome is found in roughly 5–10% of women of reproductive age. b. Untreated women who become pregnant are more likely to develop gestational hypertension and gestational diabetes. Chronic hypertension, heart disease, and diabetes risks are also increased. c. Not all women with PCOS are obese (most do have high levels abdominal fat; see Table 3.4 for other clinical signs), and the first goal of treatment is to increase insulin sensitivity. d. The first treatment for obese women with PCOS is weight loss because it enhances blood glucose control and normalizes testosterone levels, hirsutism (excess body hair), blood pressure, menstrual function, and fertility.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 3: preconception Nutrition: Conditions and Interventions

VI. Phenylketonuria (PKU) Summarize the major reasons why dietary control of phenylketonuria (PKU) is particularly important prior to pregnancy. (LO 3.5) a. Phenylketonuria (PKU) is associated with intellectual disabilities because phenylalanine cannot be converted into tyrosine and builds up in the blood. b. High blood levels of phenylalanine impair normal central nervous system development and result in intellectual disabilities. c. Strict dietary management of the pregnant female can result in an infant of normal intelligence. d. PKU is further discussed in Chapter 13. VII. Celiac Disease Describe three nutritional consequences of untreated celiac disease. (LO 3.6) a. Celiac disease (sensitivity to a protein found in gluten of wheat, rye, and barley) can cause infertility in females and males. b. Dietary management enhances fertility and embryonic development; Case Study 3.2 and Tables 3.8 and 3.9 offer examples of dietary options. VIII.

Premenstrual Syndrome Identify four common symptoms of premenstrual syndrome and the proposed effects of dietary supplements on the symptoms of premenstrual dysphoric disorder (PMDD). (LO 3.7)

a. Prior to 1987, premenstrual syndrome (PMS) was treated as a psychogenic disorder; since then, it has been reclassified as a physiologically based problem characterized by both physiological and psychological changes that disrupt a woman’s life. b. PMS occurs fairly commonly among menstruating women; a more severe form, premenstrual dysphoric disorder (PMDD), occurs in about 5% of menstruating women. c. Table 3.12 (p. 85) lists physical and psychological symptoms of PMS. d. Interventions include limiting coffee and caffeine-containing beverages; increasing daily physical activity; decreasing stressors; and supplementation with magnesium, vitamin D, calcium, and (in some instances) vitamin B6. [return to top]

DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 3: preconception Nutrition: Conditions and Interventions

1. Why is the periconceptional period (the month before and the month after conception) so crucial for embryonic development? Does following the USDA Food Patterns (www.choosemyplate.gov) ensure healthy fetal development for a couple if unprotected intercourse leads to conception? Why or why not? (LO 3.1) 2. Until the late 1980s, PMS was considered to be a psychogenic (caused by mental conflicts) condition. Explore the implications of classifying PMS as a physiologically based problem, especially as it relates to nutrition. What do you think about PMS as a topic of jokes and greeting cards? (LO 3.7) 3. A group of friends is meeting at a coffee shop, and the discussion turns to PMS: who has it, and does giving up coffee or switching to decaffeinated coffee alleviate symptoms of PMS? Based on the text and the signs and symptoms listed in Table 3.12, what is required for a diagnosis of PMS? Will a person with PMS benefit from drinking a steamed milk beverage containing no coffee rather than a cappuccino? Summarize the dietary interventions that can be made to help alleviate PMS signs and symptoms. Is it possible to rank the nutritional interventions in order of effectiveness (consider the Academy of Nutrition and Dietetics Evidence Analysis Library at https://www.andeal.org/)? (LO 3.7) 4. The text states that disordered eating can lead to irregular release of GnRH (gonadotropin-releasing hormone), very low levels of estrogen, and amenorrhea. How common are eating disorders? Is this an issue of public health concern? A review article about PMS diagnosis and treatment (Biggs WS, Demuth RH. Premenstrual syndrome and premenstrual dysphoric disorder. Am Fam Physician. 2011 Oct 15;84(8):918-24) notes that current evidence to support recommending increasing exercise or decreasing caffeine, salt, or refined sugar intakes to alleviate symptoms is not available. It mentions research revealing an association between dietary calcium and vitamin D intakes and reduced PMS symptoms. (Access the article online at http://www.aafp.org/afp/2011/1015/p918.html for details.) How would this scientific evidence affect your nutrition recommendations? (LO 3.2) 5. In Case Study 3.1, Miya faces a dilemma: maintain weight and abandon her swimming or improve fitness (i.e., decrease body fat) and potentially face another pregnancy. In both scenarios, her body weight could remain stable at 210 pounds. What happened to her body while swimming that kept weight stable and improved her fertility? Assuming she was 5 feet 10 inches tall, would a BMI calculation classify her as obese? [Yes, at 5 feet 10 inches, weighing 210 pounds translates to a BMI of 30.] (LO 3.1) 6. Blood glucose control is a concern for individuals with type 1 and type 2 diabetes and for those with insulin resistance. (LO 3.3) a. Compare and contrast nutritional aspects of type 1 and type 2 diabetes and insulin resistance. b. Discuss the implementations needed for a robust pregnancy outcome in each situation. [This topic is particularly relevant to public health practice because

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 3: preconception Nutrition: Conditions and Interventions

insulin resistance is a growing public health problem, as is type 2 diabetes, especially in some ethnic groups.] c. Apply the nutrition guidelines for diabetes. How might you answer a client asking about dietary change: “What counts as five or more servings of fruits and vegetables each day?” or “What does it mean to emphasize whole grains and high-fiber foods?” What other dietary measures could you prescribe for someone with diabetes who is contemplating becoming pregnant? 7. “High blood levels of insulin stimulate the ovaries to produce androgens (such as testosterone) and excess androgens disrupt development of follicles.” Discuss nutritional strategies that can increase insulin sensitivity (begin with diet breakdown). Lowering high insulin levels can have beneficial effects on blood triglycerides and HDL cholesterol—explain what the effects are. (LO 3.4) 8. Discuss factors that can cause PCOS. (LO 3.4) 9. Celiac disease prevalence is thought to be much higher than diagnosed cases indicate. Has someone in the class tried avoiding gluten for any length of time? What, if anything, did they find difficult about this way of eating? Make this into a homework assignment by asking members of the class to follow a gluten-free diet for 3 days and report on their experience. What are the benefits to conceptional status and fetal growth when celiac disease is controlled? (LO 3.6) [return to top]

ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. What Does Your Waist Measurement mean? (LO 3.1) Total Time: 15 minutes Obesity in men and in women impairs fertility (as does underweight). Central adiposity is indicated by a waist measurement of 35 inches or greater in females and 40 inches or greater in males. Bring tape measures to class. Have the students write down what they think their waist size is. Next, have students measure their own waist (have them measure three times and average the measurements). How close was the actual to estimated waist size (ask for a show of hands): Within 1 inch? Within 2 inches? Did they over- or underestimate their waist size? Name factors that affect the accuracy of their measurements (e.g., clothes, stretchy tape, placement of tape). Discuss the implications of self-reported measures compared to actual measures in health surveys. 2. 24-Hour Recall (LO 3.1–3.7) Total Time: 30 minutes Have students write down what they ate in one day. Instruct the students to select one of the seven conditions discussed in this chapter and review their consumption record in light of that condition. Would their diet change, and if so, how? Which foods might have to be eliminated or curtailed in portion size? Are

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 3: preconception Nutrition: Conditions and Interventions

substitutions available for each of the eliminated foods? Which foods would be encouraged, or at least acceptable, for the condition they selected? 3. Glycemic Index (LO 3.3) Total Time: 20 minutes Glycemic index (GI) alone doesn’t tell us how a food may affect blood sugar response. Learn to differentiate glycemic index from glycemic load (GL) by calculating the glycemic load of some foods students enjoy. GL = (GI × grams carbohydrate in one portion of food) divided by 100 A blueberry muffin has a glycemic index of 59 and contains 33 grams carbohydrate. To calculate the glycemic load (GL): GL = (59 × 33)/100 = 19.5 Is this healthy?

4. Complete Worksheet 3-1: Case Study—Polycystic Ovary Syndrome (LO 3.4) Total Time: 25 minutes Answer Key: 1. To increase insulin sensitivity. 2. Metformin is used in PCOS to increase insulin sensitivity, even in the absence of the diagnosis of diabetes. A beneficial side effect of metformin for many people is weight loss. 3. A weight loss of 5–10% of her initial weight would be beneficial. This would be 8.5 to 17 lb in her case. If Maria doesn’t eat fish regularly, she should consider replacing other protein foods with fish several times per week. Other important considerations: increased fruit and vegetable intake, whole grains, eating regular meals (three a day would be better than her current two a day—she may be afraid of eating too much during the day, and this would need to be addressed in nutrition counseling), low-fat foods (e.g., nonfat dairy products), and low-GI foods. Exercise is a vital part of the treatment plan for PCOS. Perhaps Maria can think of ways to exercise along with her children. 5. Maria should be advised on how to incorporate sweets in her diet in amounts and contexts that will not cause blood glucose surges and excessive insulin release. Low-GI sweets consumed with meals might be suggested. 5. Complete Worksheet 3-2: Meal Planning for Diabetes (LO 3.3) Total Time: 30 minutes Answer Key: 1. 2000 × 0.15 = 300 calories; 2000 × 0.20 = 400 calories; = 300 to 400 calories 300/4 calories per gram = 75; 400 calories/4 calories per gram = 100 grams; = 75 to 100 grams protein 2. 2000 × 0.30 = 600 calories 600/9 calories per gram = 67 grams total fat 3. 2000 × 0.5 = 1000 calories

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 3: preconception Nutrition: Conditions and Interventions

1000/4 calories per gram = 250 grams carbohydrate 4. 2000 × 0.07 = 140 calories 140/9 calories per gram = 16 grams saturated fat 5. 14 grams fiber per 1000 calories; 2000 calories recommended for this patient = 28 grams fiber total 6. Low-GI foods, 150 minutes/week of physical activity, minimal trans fat intake, 200 mg cholesterol/day maximum, 50% of grains eaten should be whole grains, and emphasize mono- and polyunsaturated fats in the diet

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 3: preconception Nutrition: Conditions and Interventions

Worksheet 3-1: Case Study—Polycystic Ovary Syndrome (LO 3.4) Maria, currently 28 years old, was diagnosed with polycystic ovary syndrome (PCOS) when she was 15. She already has two children but now that she is a busy mother, she has had great difficulty finding time to exercise and eat well, and as a result, she hasn’t lost the 20 lb she gained with her last pregnancy. Maria and her husband have been wanting to have another baby, but she wants to “get back on track” with her health first. Her physician has referred her to a registered dietitian for recommendations to help her meet her goal of weight loss. Maria’s current height and weight are 5 feet two inches and 167 lb. She reports her current meal pattern includes two small meals per day and other than “chasing my children,” she gets no regular physical activity. Maria tries very hard to limit sweets but admits to breaking down and eating an entire bag of chocolates at least once a week. Her physician prescribed metformin for her, but she doesn’t understand why she should take this medication if she doesn’t have diabetes. Questions: 1. What is the primary goal of treatment for PCOS?

2. Why should Maria be encouraged to take the metformin her physician prescribed for her?

3. What is a realistic weight loss goal for Maria that would be therapeutic?

4. What nutrition and lifestyle recommendations do you have for her?

5. What recommendation do you have for Maria regarding her intake of sweets?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 3: preconception Nutrition: Conditions and Interventions

Worksheet 3-2: Meal Planning for Diabetes (LO 3.3) Using the guidelines from the American Diabetes Association for patients with type 2 diabetes (Nutrition recommendations and interventions for diabetes. A position statement of the American Diabetes Association. Diabetes Care Jan. 2008, vol. 31, supp. 1, S61-S78; available from the journal’s website at http://diabetesjournals.org/care/article/31/Supplement_1/S12/24521/Standards-ofMedical-Care-in-Diabetes-2008), complete the following calculations for a person on a 2000-calorie diet. 1. How many calories should come from protein? How many grams of protein would that be?

2. How many calories should come from fat? How many grams of fat would that be?

3. How many calories should come from carbohydrate? How many grams of carbohydrate would that be?

4. How many grams of saturated fat would be equal to the upper limit recommended?

5. How many grams of fiber would be recommended for this person?

6. What general dietary recommendations would you also suggest?

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 3: preconception Nutrition: Conditions and Interventions

ADDITIONAL RESOURCES INTERNET RESOURCES Science of Nutrition • Diabetes resources: o American Diabetes Association: http://www.diabetes.org o National Institute of Diabetes and Digestive and Kidney Disorders: http://www.niddk.nih.gov/ o Canadian Diabetes Association: http://www.diabetes.ca o Joslin Diabetes Center: http://www.joslin.org • National Library of Medicine (PubMed): http://www.ncbi.nlm.nih.gov/PubMed • National Academies of Science, Engineering, and Medicine: http://www.nationalacademies.org/hmd/ • Celiac disease resources: o Celiac Disease Foundation: http://www.celiac.org o National Celiac Association: http://nationalceliac.org o Gluten Intolerance Group: http://www.gluten.org o Raising Our Celiac Kids: http://www.raisingourceliackids.com o Resource guide for gluten-free diets: https://www.celiac.ca/livinggluten-free/diet-nutrition/ Nutrition Assessment • USDA’s Food and Nutrition Information Center: http://www.nal.usda.gov/programs/fnic Preconception Nutrition—Conditions & Interventions • NIH Office of Dietary Supplements: http://ods.od.nih.gov/ • PCOS Resources: o PolyCystic Ovarian Syndrome Association, Inc. (PCOS Support): http://www.PCOSupport.org o Office of Disease Prevention and Health Promotion: Search PCOS at http://health.gov/myhealthfinder Nutritional Health •

FDA/Women’s Health: http://www.fda.gov/consumers/womens-health

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 4: NUTRITION DURING PREGNANCY

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 5 Chapter Outline ................................................................................................................... 5 Discussion Questions........................................................................................................ 10 Additional Activities and Assignments ............................................................................. 11 Additional Resources ........................................................................................................ 16 Internet Resources.................................................................................................................. 16

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to address the physiological changes that take place to accommodate pregnancy and discuss the impact of these changes on maternal nutritional needs. The chapter addresses the status of pregnancy outcomes in the United States and other countries. The roles of nutrition in fostering fetal growth, development, and long-term health are covered, along with dietary supplement use and weight-gain recommendations.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 4.1

Identify three problem areas related to pregnancy outcomes in the United States.

4.2

Describe five physiological changes that normally occur during pregnancy that would be considered abnormal if they did not occur during pregnancy.

4.3

Correlate critical periods of growth and development and the potential consequences of inadequate energy and nutrient availability during these periods on future health status.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

4.4

Identify recommended weight gain ranges for women who enter pregnancy underweight, normal weight, overweight, and obese.

4.5

Correlate three examples of relationships between nutritional status during pregnancy and long-term health outcomes in offspring.

4.6

Provide five examples of how the need for energy and specific nutrients changes due to pregnancy.

4.7

Identify three factors that influence dietary intake during pregnancy that are not related to food availability.

4.8

Develop a one-day diet for pregnancy based on MyPlate.gov food intake recommendations for pregnancy.

4.9

Describe two reasons why pregnant women and their fetuses are particularly vulnerable to certain foodborne illnesses.

4.10

Identify the basic components of a nutritional assessment of pregnant women.

4.11

Identify three health benefits to women of regular exercise during pregnancy.

4.12

Assess three common health problems during pregnancy and the evidence on the effectiveness of dietary interventions for their treatment or amelioration.

4.13

Describe the nutrition service components of a model nutrition program during pregnancy.

KEY TERMS Liveborn infant: A liveborn infant is the outcome of delivery when a completely expelled or extracted fetus breathes, or shows any sign of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the cord has been cut or the placenta is still attached. Placenta: A disk-shaped organ of nutrient and gas interchange between mother and fetus. At term, the placenta weighs about 15 percent of the weight of the fetus. Edema: Swelling (usually of the legs and feet but can also extend throughout the body) due to an accumulation of extracellular fluid. Steroid hormones: Hormones such as progesterone, estrogen, and testosterone produced primarily from cholesterol. Glucogenic amino acids: Amino acids such as alanine and glutamate that can be converted to glucose.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

Ketones: Metabolic by-products of the breakdown of fatty acids in energy formation. β-hydroxybutyric acid, acetoacetic acid, and acetone are the major ketones, or ketone bodies. Amniotic fluid: The fluid contained in the amniotic sac that surrounds the fetus in the uterus. Growth: Increase in an organism’s size through cell multiplication (hyperplasia) and enlargement of cell size (hypertrophy). Development: Progression of the physical and mental capabilities of an organism through growth and differentiation of organs and tissues, and integration of functions. Differentiation: Cellular acquisition of one or more characteristics or functions different from that of the original cells. Critical periods: Pre-programmed time periods during embryonic and fetal development when specific cells, organs, and tissues are formed and integrated, or functional levels established. Also called sensitive periods. Small for gestational age (SGA): Newborn weight is less than 10th percentile for gestational age. Also called small for date (SFD). Disproportionately small for gestational age (dSGA): Newborn weight is less than 10th percentile of weight for gestational age; length and head circumference are normal. Also called asymmetrical SGA. Proportionately small for gestational age (pSGA): Newborn weight, length, and head circumference are less than 10th percentile for gestational age. Also called symmetrical SGA. Appropriate for gestational age (AGA): Weight, length, and head circumference are between the 10th and 90th percentiles for gestational age. Large for gestational age (LGA): Weight for gestational age exceeds the 90th percentile for gestational age. Also defined as birthweight greater than 4500 g (10 lb) and referred to as excessively sized for gestational age, or macrosomic. Shoulder dystocia: Blockage or difficulty of delivery due to obstruction of the birth canal by the infant’s shoulders. Cerebral palsy: A group of disorders characterized by impaired muscle activity and coordination present at birth or developed during early childhood. Developmental plasticity: The concept that development can be modified by particular environmental conditions experienced by a fetus or infant.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

Epigenetic: (epi = over, above) Heritable changes in gene function that do not entail a change in DNA sequence. Epigenetic modifications play a crucial role in the silencing and expression of noncoding portions of genes. Gravida: Number of pregnancies a woman has experienced. Parity: The number of previous deliveries experienced by a woman; nulliparous = no previous deliveries, primiparous = one previous delivery, multiparous = two or more previous deliveries. Women who have delivered infants are considered to be parous. Microbiome: The totality of microorganisms (bacteria, viruses, bacteriophages, and fungi) along with their collective genetic materials present in or on the human body. Eicosanoids: Molecules synthesized from essential fatty acids. They exert complex control over many bodily systems, mainly in inflammation and immunity, and act as messengers in the central nervous system. Iron-deficiency anemia: A condition often marked by low hemoglobin level. It is characterized by the signs of iron deficiency plus paleness, exhaustion, and a rapid heart rate. Hypothyroidism: A condition characterized by growth impairment, intellectual disabilities, and deafness when caused by inadequate maternal intake of iodine during pregnancy. Used to be called cretinism. Bioactive food components: Constituents in foods or dietary supplements other than those needed to meet basic human nutritional needs that are responsible for changes in health status. Pica: An eating disorder characterized by the compulsion to eat substances that are not food. Dysgeusia: Changes in taste. During pregnancy, changes are thought to be caused by hormonal changes. Geophagia: Compulsive consumption of clay or dirt. Pagophagia: Compulsive consumption of ice or freezer frost. Amylophagia: Compulsive consumption of laundry starch or cornstarch. L. monocytogenes, or listeria: A foodborne bacterial infection that can lead to preterm delivery and stillbirth in pregnant women. Listeria infection is commonly associated with the ingestion of soft cheeses, unpasteurized milk, ready-to-eat deli meats, and hot dogs. T. gondii, or toxoplasmosis: A parasitic infection that can impair fetal brain development. The source of the infection is often hands contaminated with soil or the contents of a cat litter box; or raw or partially cooked pork, lamb, or venison.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

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WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • • • • • • • • •

Updated DRI for energy during pregnancy Updated infant mortality rate per 1000 births chart Indicated the heart is the first functional organ to develop Expanded section on intrauterine growth restriction (IUGR), including fetal growth restriction as the updated terminology Described impact of obesity on miscarriage risks and rates Updated mortality charts for both women and infants Revised birthweight by gestational age chart Updated rates of preterm delivery, low birthweight in the United States by ethnic backgrounds Updated Fish Advice image Updated food safety guidelines image

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CHAPTER OUTLINE I.

Introduction a. Fetal growth and development during gestation is the most intense growth period in a human life. b. Chapter 4 highlights the impact of nutrition on birth outcomes in the United States and other countries; relationships among gestation, birth outcomes, and long-term health are discussed.

II. The Status of Pregnancy Outcomes Identify three problem areas related to pregnancy outcomes in the United States. (LO 4.1) a. Several time-related terms will make this section easier to follow. Some of the key terms are presented graphically in Figure 4.1. b. Table 4.1 presents natality statistics from 1995 thru 2021 and definitions of the terms. c. Statistics such as those for infant mortality and birthweight help to describe the nutrition and health status of a population; these statistics also serve to identify potential trouble spots or areas where intervention may improve public health.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

d. Defining what constitutes a liveborn infant is a crucial element in tracking health. e. Brief reminder for interpreting birth weights: 16 ounces = 453.59 g = 1 lb. 1 ounce = 28.35 g. f. This section also includes a listing of the 2030 national health objectives related to pregnant women and infants (Table 4.4).

III. Physiology of Pregnancy Describe five physiological changes that normally occur during pregnancy that would be considered abnormal if they did not occur during pregnancy. (LO 4.2) a. Phases of pregnancy are grouped by anabolic and catabolic functions occurring during the first and second halves of the gestational period (see Table 4.6). b. Metabolism changes, and many lab values that are abnormal for a nonpregnant woman are acceptable during pregnancy. c. “The fetus is not a parasite” highlights the fact that maternal nutrition can affect fetal growth and development positively or negatively. “The fetus is not a parasite” is a core concept for this section. d. To help explain this, mechanisms of nutrient transport across the placenta are summarized in Table 4.9. e. “Normal changes in maternal physiology during pregnancy” (Table 4.6) briefly summarizes this content-dense section by highlighting the wide-ranging effects of physiological changes during pregnancy. f. No single system changes without ripple effects on others; there is overlap among affected systems. g. Any student who can generate a table similar to Table 4.6 and discuss the food and nutrition implications of affected system changes demonstrates an excellent understanding of the physiology of pregnancy.

IV. Embryonic and Fetal Growth and Development Correlate critical periods of growth and development and the potential consequences of inadequate energy and nutrient availability during these periods on future health status. (LO 4.3) a. This section reiterates the introduction and elaborates on the core of this chapter: growth and development are greater during gestation than during any other period in life. b. Hyperplasia, or increased cell multiplication, characterizes these critical periods (e.g., for forebrain development, see Figure 4.7). c. Meeting nutritional needs throughout gestation, but especially during critical periods, fosters a good birth outcome and may help to avoid undesirable consequences later in life such as allergies, short stature, subfertility in males, and obesity.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

d. Developmental origins of health and disease: The developmental programming of later disease risk concept suggests that programming occurs during sensitive developmental periods. It also presents a reasonable mechanism for programming. e. Table 4.14 presents data associating birthweight with the relative risks of heart disease and stroke.

V. Pregnancy Weight Gain Identify recommended weight gain ranges for women who enter pregnancy underweight, normal weight, overweight, and obese. (LO 4.4) a. Weight gain recommendations are based on a woman’s pre-pregnancy weight (Table 4.15). b. Rates of gain further affect pregnancy outcomes. c. Typical weight gain patterns for obese, normal weight, and underweight women can be explained using Figure 4.9, Table 4.15, and Figure 4.10. d. The usual question about why so much maternal weight needs to be gained for a 7- to 10-pound infant is answered in Table 4.16, which lists the components of weight gain as well as the points in pregnancy when this weight is added.

VI. Nutrition and the Course and Outcome of Pregnancy Correlate three examples of relationships between nutritional status during pregnancy and long-term health outcomes in offspring. (LO 4.5) a. Much folklore and research surrounds pregnancy. b. Historically, food shortages during war and famine have led to declines in fertility as well as newborn health and survival. c. The siege of Sarajevo in the 1990s is a more recent example of the effects of food shortages on reproduction.

VII. Energy and Nutrient Needs During Pregnancy Provide five examples of how the need for energy and specific nutrients changes due to pregnancy. (LO 4.6) a. The section covers the need for macro- and micronutrients, as well as caffeine and alcohol consumption in relation to pregnancy outcomes. b. The need for fat: Specific requirements for fat are addressed, with special attention to omega-3 and omega-6 fatty acids. c. Two of the omega-3 fatty acids, EPA and DHA, are discussed, presenting their unique role in the development of the central nervous system. d. The need for vitamins and minerals during pregnancy: Vitamins that play a special role in pregnancy are covered in this section.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

e. Of particular interest is folate because of its role in preventing neural tube defects. f. Vitamins A and D as well as choline are highlighted. g. Minerals that are of special interest during pregnancy are covered in this section. h. Iron is of particular interest due to the high rate of iron deficiency and the difficulty in obtaining adequate iron for pregnancy from diet alone. i. Other minerals of interest include calcium, fluoride, iodine, and sodium. j. Bioactive components of food: Foods contain thousands of biologically active substances that are not considered essential nutrients but nonetheless influence health, including maternal health. k. Antioxidant pigments and caffeine are two primary examples of bioactive food components that have been investigated for effects on maternal and newborn health and are discussed in this section.

VIII.

Factors Affecting Dietary Intake During Pregnancy Identify three factors that influence dietary intake during pregnancy that are not related to food availability. (LO 4.7)

a. This section discusses how changes in taste and smell during pregnancy can affect dietary intake. b. Pregnant women who crave nonfood items (such as ice chips or laundry starch) are classified as having an eating disorder called pica. c. Food intake during pregnancy is also heavily influenced by cultural factors.

IX. Healthy Dietary Patterns for Pregnancy Develop a one-day diet for pregnancy based on MyPlate.gov food intake recommendations for pregnancy. (LO 4.8) a. Diets that are considered to be healthful for pregnancy share a number of characteristics, as described in Table 4.24. b. One of the most important elements is supporting appropriate maternal weight gain by consuming sufficient calories. c. Vegetarian diets in pregnancy: Diets that do not contain animal products can still support a successful pregnancy. d. ChooseMyPlate.gov as well as Tables 4.28 and 4.29 in the textbook provide guidance on how to plan a vegetarian or vegan diet. e. Dietary supplements during pregnancy: Multivitamin and mineral supplements are routinely recommended to pregnant women by most clinicians in the United States, and many women use nutrient and herbal supplements on their own. f. Pregnant women should try to meet their nutrient needs through consuming a well-balanced and adequate diet.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

g. Some women may be in need of a supplement because they smoke or follow a vegan diet (among other reasons). h. Many women consume a variety of herbs during pregnancy. i. About a third of those herbs used (see Table 4.30) possess traits deemed unsafe for pregnancy and can greatly disrupt the normal development of the fetus. X. Food Safety During Pregnancy Describe two reasons why pregnant women and their fetuses are particularly vulnerable to certain foodborne illnesses. (LO 4.9) a. Pregnant women are less able to resist infectious diseases due to increased progesterone levels. b. The placenta does not protect the infant from foodborne infections. c. Listeria and toxoplasmosis are highlighted in Figure 4.19. XI. Assessment of Nutritional Status During Pregnancy Identify the basic components of a nutritional assessment of pregnant women. (LO 4.10) a. A nutritional assessment during pregnancy is recommended, particularly for women who have gestational diabetes or other medical conditions. b. Another type of assessment is a nutrition biomarker assessment, where blood is drawn and analyzed for concentrations of specific nutrients like iron. XII. Exercise and Pregnancy Outcome Identify three health benefits to women of regular exercise during pregnancy. (LO 4.11) a. Exercise during pregnancy benefits both mother and fetus, and it is encouraged. b. Recommendations are similar to those for other healthy women. XIII.

Common Health Problems During Pregnancy Assess three common health problems during pregnancy and the evidence on the effectiveness of dietary interventions for their treatment or amelioration. (LO 4.12)

a. Physiological changes of pregnancy may be accompanied by side effects such as nausea, vomiting, heartburn, and constipation. b. Management of these conditions should be individualized, and this section suggests several nutritional approaches to deal with them. XIV.

Model Nutrition Programs for Risk Reduction in Pregnancy Describe the nutrition service components of a model nutrition program during pregnancy. (LO 4.13)

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

a. Many critical periods throughout the complex process of pregnancy affect subsequent health. b. Good nutrition can foster growth and development, and lack of food or poor nutrition can cause permanent damage. c. Effective nutrition programs begin before conception and provide follow-up after delivery. d. Exemplary programs include the Montreal Diet Dispensary and the WIC Program, which provides assessment, vouchers for nutritious foods, education, and some health care services. [return to top]

DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class. 1. Clarify terms that may be confusing to students (e.g., liveborn and stillborn). Why is it useful for nutritionists to understand the terms and statistics listed in Table 4.1? (LO 4.1) 2. Where do serious food shortages currently exist in the world? How can you expect this to affect fertility and pregnancy outcomes? [Pages 106-107 describe effects of famine during the Dutch Hunger Winter, the Siege of Leningrad, Japan during World War II, and the Chinese famine of 1959–1961.] (LO 4.5) 3. Discuss the effects of pregnancy on maternal metabolism. For carbohydrates, what are the “diabetogenic effects of pregnancy,” and what are strategies to deal with insulin resistance when it develops? Summarize the discussion by relating highlights to the maternal physiological changes highlighted in Table 4.6. (LO 4.2) 4. How is protein intake affected during pregnancy? [Up to 2 pounds of protein are accumulated during pregnancy. Maternal intake is increased, and the body conserves nitrogen.] (LO 4.2) 5. What is the role of omega-3 fatty acids like DHA in fetal development? [See pp. 110–111.] Why is a maternal atherogenic lipid profile acceptable during the third trimester of pregnancy? What, if any, are the alterations of fat metabolism during pregnancy? (LO 4.6) 6. Discuss the distinctions between the two phases of pregnancy—“maternal anabolic” and “maternal catabolic”—in fetal development and growth. How does this 2-phase concept relate to the statement “The fetus is not a parasite”? (LO 4.2)

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

7. Why does an obese woman need to gain 11–20 pounds during pregnancy? Can’t she just convert her excess body fat for fetal growth? [Illustrations 4.12, 4.13, and 4.14 show rates of weight gain; Figure 4.12 displays the components of increased oxygen consumption in normal pregnancy.] (LO 4.3 & 4.6) 8. What is the prevalence of nausea and vomiting during pregnancy? When is nausea the most common in pregnancy? What are strategies to maintain dietary intake during periods of nausea? (LO 4.3) 9. Excess alcohol causes irreversible damage to a fetus. Do you think requiring warning labels on beer, wine, and spirits is enough action on the government’s part to prevent alcohol-related problems? What other regulations should there be to reduce alcohol’s damage during fetal development? Should these apply to men as well as women, and if so, why? (LO 4.6) 10. Discuss the statement “Food is best” as it applies to folate intake and recommendations (Figure 4.20). [This can be a good opportunity to discuss vitamin B12 deficiency and folate’s masking effects.] (LO 4.6) 11. NTDs (neural tube defects) can be the result of inadequate folic acid during days 21–27 after conception. Discuss the social or policy aspects of folic acid fortification, preconceptual nutrition, and nutrition intervention during pregnancy. (LO 4.6) [return to top]

ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. Physiology Changes During Pregnancy (LO 4.2) Total Time: 30 minutes Divide the class into small groups. Assign each team (or have them choose) one of the physiological changes from Table 4.6. For example, assign blood volume expansion and hemodilution and have students develop an intervention approach to help pregnant women eat well during this physiological change. 2. Weight Gain During Pregnancy (LO 4.4) Total Time: will vary Assign homework to teams of two and ask that they develop a detailed outline for a 10-minute teaching module on weight gain during pregnancy. In class, ask for a volunteer (or have each team duo select a presenter) to present their outline to the rest of the class. The class will role-play that they are attending the prenatal class. They are expected to ask questions along the way. Debrief after the session (with the instructor as facilitator) and clarify information where necessary. [This can be an opportunity to clarify BMI cut points, rate of gain, critical developmental periods, nausea and weight, and other nutritional concerns.]

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

3. Vegetarian Diets in Pregnancy (LO 4.8) Total Time: 35 minutes Divide the class into 4 groups. Each group should choose 2–3 basics of a good diet for normal pregnancy found in Table 4.28 to discuss. After choosing these basics, students will then discuss and provide examples of how individuals on a vegan or vegetarian diet can meet these basic needs. Debrief by relating the student findings to the summary presented in Table 4.28: Recommended amounts of food from the food groups during pregnancy. 4. Complete Worksheet 4-1: Case Study—Difficulty Gaining Weight During Pregnancy (LO 4.4) Total Time: 30 minutes Answer Key: 1. According to Figure 4.10, Melissa should have gained closer to 13 pounds by her 22nd week of pregnancy. Based on her pre-pregnancy BMI of 21.8 kg/m2 and the decreased risk of delivering a small infant if she gains adequate weight during pregnancy, a total weight gain goal would be approximately 30 pounds (Table 4.15). 2. First and foremost, Melissa needs an individualized approach to the management of her nausea and vomiting. Suggestions include separate liquids and solid foods, avoid odors that are offensive to her, and eat foods that she tolerates well. Encourage her not to follow the advice in popular magazines unless it is from a registered dietitian. She needs to monitor her fluid status frequently and stay in close contact with her physician. The registered dietitian she is seeing could help her design a meal plan based on foods she tolerates to provide the amounts of foods from each food group that are recommended for pregnancy (Tables 4.28 and 4.29). 3. Vitamin B12 is not a recommended supplement to help with the management of nausea and vomiting in pregnancy. Melissa should be advised to discontinue this supplement. Supplements she should consider include vitamin B6 (10- to 25-mg dose every 8 hours), ginger (1 g/day for 4 days), and a multivitamin with minerals. A prescription medication combining B6 with doxylamine is another option. 5. Complete Worksheet 4-2: Nutritional Requirements During Pregnancy (LO 4.6) Total Time: 30 minutes Answer Key: 1. Based on a BMI of 21.6 kg/m2, the recommended weight gain for the entire pregnancy is 25–35 pounds. 2. Calorie needs during pregnancy vary based on the woman’s activity level, among other factors, and caloric intake is best assessed indirectly based on rate of weight gain. The DRIs for energy intake for pregnancy are 1340 kcal per day for the second trimester and 1452 kcal per day for the third trimester of pregnancy. Additional energy requirements have been found by different studies to range from 210 to 570 kcal a day.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

3. Answers will vary but could include: 2 cups 2% milk, 1 fruit exchange, 1 bread exchange, and 1 ounce lean meat. 4. 25 grams protein per day (DRI); 2 cups milk, 1 ounce meat, and 1 vegetable exchange. 5. During the last quarter of pregnancy, the body needs approximately 300 mg/day more than the nonpregnancy DRI of calcium. 6. For adult females, the DRI increases from 18 to 27 mg of iron. 7. For adult females, the DRI increases from 400 to 600 mcg DFE. Of this intake, 400 mcg should be in the form of folic acid from fortified foods or supplements. The remaining 200 mcg DFE should be obtained from vegetables and fruits. 8. No; contrary to popular belief, nutrition needs do not increase drastically in pregnancy. However, it’s still vital to meet 100% of nutrition needs during pregnancy.

Worksheet 4-1: Case Study—Difficulty Gaining Weight During Pregnancy (LO 4.4) Melissa has been referred to a registered dietitian for assistance with gaining weight. She is in her 22nd week of pregnancy and was recently diagnosed with hyperemesis gravidarum. Her physician is concerned that she has gained only 5 pounds thus far in her pregnancy. Prior to becoming pregnant, her weight was 135 pounds, and she is 5 feet 6 inches. Melissa tells you she has been following the dietary advice for nausea provided in a popular pregnancy magazine, but it just doesn’t seem to be working for her. She also wonders if she is consuming adequate nutrition for her baby and asks you if she should be taking any nutrition supplements. She stopped taking her prenatal vitamins last week to see if this might decrease her nausea. Melissa heard from a friend that vitamin B12 supplements are supposed to help with nausea, so she has been taking those for a few days, but they don’t seem to be helping. A 24-hour food recall shows the following: 3 ounces grains, no vegetables, 1 ½ cups fruits, 2 cups milk, 3 ounces meat, and 1–2 teaspoons of fat.

Questions:

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

1. Approximately how much weight should Melissa have gained by now? What is the total recommended weight gain in light of her diagnosis of hyperemesis gravidarum?

2. What recommendations do you have for the management of nausea and vomiting during pregnancy that would apply to Melissa’s case?

3. Are there nutrition supplements that might be beneficial to Melissa?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

Worksheet 4-2: Nutritional Requirements During Pregnancy (LO 4.6) Directions: Use the information in Chapter 4 to complete this worksheet. 1. Heidi, 28 years old, just found out she is pregnant. She weighs 134 lb and is 5 feet 6 inches. Calculate her current BMI and recommend the amount of weight she should gain during her pregnancy.

2. How many calories per day should Heidi consume to support her pregnancy?

3. How much food would be needed to provide the additional energy needed in the third trimester based on the DRI? Hint: Use the ADA Exchange System to estimate the amount of food that would be needed.

4. How much additional protein is needed to meet the nutritional requirements of the pregnancy? How much extra food would this be? Hint: Use the ADA Exchange System to estimate the amount of food that would be needed.

5. How will Heidi’s calcium needs change during pregnancy?

6. How will her DRI for iron change to meet the nutritional requirements of pregnancy?

7. How will her DRI for folate change to meet the nutritional requirements of pregnancy? 8. Considering the answers to the above questions, is the statement “I can eat as much as I want to during pregnancy because I’m eating for two” really accurate?

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

ADDITIONAL RESOURCES INTERNET RESOURCES ●

●

Nutrition research o

National Library of Medicine (Medline Plus): https://medlineplus.gov

National Library of Medicine (PubMed): http://www.ncbi.nlm.nih.gov/pubmed

General nutrition o

Nutrition Information for you: http://www.nutrition.gov

USDA Food and Nutrition Information Center (ethnic diets/cultural beliefs): http://www.nal.usda.gov/human-nutrition-and-foodsafety/international-nutrition

Science of nutrition o

●

Nutrition assessment tools o

●

United States ▪

Healthy People: Objectives for the Nation: http://health.gov/healthypeople

▪

WIC: http://www.fns.usda.gov/wic/

Canada—Health Canada: http://www.hc-sc.gc.ca

Nationwide priorities and nutritional health o

●

National Center for Education in Maternal and Child Health: http://ncemch.org/

Public food and nutrition programs o

●

USDA’s Food and Nutrition Information Center: http://www.nal.usda.gov/programs/fnic

Nutrition during pregnancy o

●

Institute of Medicine/Food and Nutrition Board: http://www.nationalacademies.org/fnb/food-and-nutrition-board

United States—Environmental Protection Agency (information on mercury levels in fish): http://www.epa.gov/choose-fish-and-shellfishwisely

Effects of alcohol on pregnancy outcomes o

National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism (NIAAA)

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 4: Nutrition During Pregnancy

▪

“Drinking and Your Pregnancy”: http://pubs.niaaa.nih.gov/publications/DrinkingPregnancy_HTML /pregnancy.htm

▪

“Fetal Alcohol Exposure”: http://pubs.niaaa.nih.gov/publications/FASDFactsheet/FASDfact. htm

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 5: Nutrition During Pregnancy: Conditions and Interventions

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 5: NUTRITION DURING PREGNANCY : CONDITIONS AND INTERVENTIONS

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 3 Chapter Outline ................................................................................................................... 3 Discussion Questions.......................................................................................................... 5 Additional Activities and Assignments .............................................................................. 6 Additional Resources ......................................................................................................... 11 Internet Resources.................................................................................................................. 11

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to discuss and address several health conditions and the role of nutrition in their etiology and management. The chapter highlights specific conditions related to people with obesity, hypertensive disorders of pregnancy, diabetes in pregnancy, multifetal pregnancy, eating disorders, fetal alcohol spectrum disorders, and adolescent pregnancy.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 5.1

Cite three specific examples of nutrition-related recommendations intended for women who enter pregnancy with obesity.

5.2

Distinguish the different types of hypertensive disorders that occur during pregnancy, and connect two components of nutrition care recommended for women with each type.

5.3

Connect the different, major types of disorders in carbohydrate metabolism that occur during pregnancy and the key components of the nutritional management of each type.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 5: Nutrition During Pregnancy: Conditions and Interventions

5.4

Explain three differences in nutrient needs and cite two specific considerations for delivery of effective nutritional care for women with multifetal pregnancy.

5.5

Identify two primary components of the nutritional care of women with eating disorders during pregnancy.

5.6

Summarize the consequences of excess alcohol intake during pregnancy, and list four factors that affect the relationship between alcohol intake and the outcome of pregnancy.

5.7

Distinguish three ways in which energy and nutrient needs differ between adults and adolescents during pregnancy.

KEY TERMS Preeclampsia: A condition that is typically diagnosed after the 20th week of pregnancy. It is characterized by blood pressure readings that exceed 140/90 mmHg documented on two occasions by blood pressure measurements made at least four hours apart. Dumping syndrome: A condition characterized by weakness, dizziness, flushing, nausea, and palpitation immediately or shortly after eating and produced by abnormally rapid emptying of the stomach, especially in individuals who have had part of the stomach removed. Gestational diabetes: Carbohydrate intolerance with onset of, or first recognition in, pregnancy. Endothelium: The layer of cells lining the inside of blood vessels. Placenta abruption: The separation of the placenta from its attachment to the uterus wall before the baby is delivered. Also called abruptio placenta. Consequences of this condition range from mild to severe for the mother and fetus depending on blood loss, extent of fetal distress, gestational age of the fetus, and other factors. Congenital anomalies: Structural, functional, or metabolic abnormalities present at birth. Also called congenital abnormalities. Hemoglobin A1c: A form of hemoglobin used to identify blood glucose levels over the lifetime of a red blood cell (120 days). Glucose molecules in blood will attach to hemoglobin (and stay attached). The amount of glucose that attaches to hemoglobin is proportional to levels of glucose in the blood. The normal range of hemoglobin A1c is 4–5.9%. Also called glycosylated hemoglobin and glycated hemoglobin. Macrosomia: A newborn with an excessive birth weight (macro = big, somia = body). Newborn macrosomia has been defined in several different ways, including birth

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 5: Nutrition During Pregnancy: Conditions and Interventions

weight of 4000–4500 g (8 lb 13 oz to 9 lb 15 oz) or greater than the 90th percentile of weight for gestational age. Assisted reproductive technology (ART): An umbrella term for fertility treatments such as in vitro fertilization (IVF, a technique in which egg cells are fertilized by sperm outside the woman’s body), artificial insemination, and hormone treatments. Cephalopelvic disproportion: A mismatch between the size of the fetal head and the size of the maternal pelvis, resulting in “failure to progress” in labor for mechanical reasons. [return to top]

WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • • • • • •

Updated pregnancy outcomes related to pre-pregnancy weight Expanded section on bariatric surgery to include more updated surgery options New section on metabolic surgery as one of the reasons for undergoing bariatric surgery Strengthened section on gestational diabetes Updates on risk factors impacting pregnancy Strengthened section on multifetal pregnancy Updated data on twin birth weights

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CHAPTER OUTLINE I.

Introduction a. The expectation of a healthy newborn is fulfilled for “the vast majority of pregnancies.” b. Chapter 5 deals with special conditions of pregnancy and with corresponding interventions.

II. Obesity and Pregnancy Cite three specific examples of nutrition-related recommendations intended for women who enter pregnancy with obesity. (LO 5.1) a. Obesity prior to pregnancy is associated with higher rates of gestational diabetes and hypertensive disorders of pregnancy. b. Excessive visceral fat increases disease risk as compared to subcutaneous fat.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 5: Nutrition During Pregnancy: Conditions and Interventions

c. Nutritional as well as surgical interventions for obesity treatment are discussed. III. Hypertensive Disorders in Pregnancy Distinguish the different types of hypertensive disorders that occur during pregnancy and connect two components of nutrition care recommended for women with each type. (LO 5.2) a. Affecting 5–10% of pregnancies, hypertensive disorders of pregnancy (see Table 5.2) stem largely from unknown causes; cures are elusive for affected women. b. Weight gain recommendations match those for women without hypertension. c. The importance of this topic is emphasized by Tables 5.3, 5.4, 5.5, and 5.6, which deal with issues related to preeclampsia. d. Ashley’s story in Case Study 5.1 facilitates the application of nutrition recommendations for preeclampsia, one of the hypertensive disorders of pregnancy. IV. Diabetes in Pregnancy Connect the different, major types of disorders in carbohydrate metabolism that occur during pregnancy and the key components of the nutritional management of each type. (LO 5.3) a. Allow the student to describe the role of insulin resistance and to distinguish between type 1 and type 2 diabetes’s effects on maternal health and on the developing fetus. b. Students will also discover, and should be able to discuss, the close relationship between gestational diabetes and type 2 diabetes. c. The role of the glycemic index in the management of diabetes in pregnancy is discussed, and a sample meal plan is provided (using low-glycemic-index foods) in Table 5.11. V. Multifetal Pregnancies Explain three differences in nutrient needs and cite two specific considerations for delivery of effective nutritional care for women with multifetal pregnancy. (LO 5.4) a. Twin and triplet pregnancy rates have increased, especially in older women and in women achieving pregnancy with assistive reproductive technologies. b. Pre-pregnancy weight affects weight gain recommendations for a pregnancy with multiples (Table 5.16; heavier women need to gain proportionately less weight). c. Best practices for healthy outcomes in multifetal pregnancy are summarized in Table 5.17. d. Multifetal pregnancies pose greater risks than singleton pregnancies.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 5: Nutrition During Pregnancy: Conditions and Interventions

e. The 3% of newborns resulting from multifetal pregnancies “account for disproportionally high percentages of all low-birthweight newborns, preterm births, and infant deaths.” VI. Eating Disorders in Pregnancy Identify two primary components of the nutritional care of women with eating disorders during pregnancy. (LO 5.5) a. It is recommended that women and pregnant women with eating disorders be referred to a program that uses a team approach to support maternal and fetal health. b. Because eating disorders are associated with sub- or infertility, pregnancy in women with diagnosed eating disorders is uncommon. VII. Fetal Alcohol Syndrome Summarize the consequences of excess alcohol intake during pregnancy, and list four factors that affect the relationship between alcohol intake and the outcome of pregnancy. (LO 5.6) a. Fetal alcohol syndrome is the term used to describe the range of effects of alcohol consumed during pregnancy on fetal development. b. Abstinence from alcohol is recommended during pregnancy because alcohol that a pregnant woman consumes can easily cross the placenta and reach the fetus. VIII.

Nutrition and Adolescent Pregnancy Distinguish three ways in which energy and nutrient needs differ between adults and adolescents during pregnancy. (LO 5.7)

a. Despite declining teen pregnancy rates, the United States has one of the highest adolescent pregnancy rates of developed countries. b. The risks of poor outcomes may be due more to lifestyle factors than biological immaturity. c. The high potential for detrimental, long-term consequences is balanced by treatment that supports teen, as well as fetal, growth and development. d. Evidence-based practice: Research-based and “best-practice” protocols can enhance the outcomes of problematic pregnancies; continually striving to evaluate and update current practices will foster public health. [return to top]

DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 5: Nutrition During Pregnancy: Conditions and Interventions

1. Hypertensive disorders of pregnancy are the second leading cause of maternal mortality in the United States. Discuss the relationship between hypertensive disorders of pregnancy (Table 5.2), chronic hypertension, and outcomes related to preeclampsia (see Table 5.5). Begin by defining hypertension. (LO 5.2) 2. What are preventive measures and nutritional interventions associated with preeclampsia? How would you prioritize this long list of potentially helpful nutrition interventions? (LO 5.2) 3. In Case Study 5.1, what are the critical pieces of information? [Some include proteinuria levels, insulin resistance, infant’s weight, and delivery at 36 weeks.] What other questions would you ask if you were the dietitian in this scenario? What sort of dietary advice would you give to Ashley to treat her preeclampsia? (LO 5.2) 4. Describe an oral glucose tolerance test (OGTT). Discuss the pros and cons of using the OGTT in the diagnosis of gestational diabetes. How does the determination of glucose tolerance during pregnancy differ from the process used for nonpregnant women? (LO 5.3) 5. Potential consequences of poorly controlled gestational diabetes (see Table 5.7) include increased risk of chronic disease later in life. What aspects of the meal plan found in Table 5.11 would make it suitable for a pregnant woman with gestational diabetes? (LO 5.3) 6. Assume that you are developing a health promotion campaign aimed at Pima women of conceptual age. What nutritional and exercise considerations might such a campaign include? What, if anything, would you do about the young males of this age? (LO 5.3) 7. How would you explain to a young woman that it is a good idea to eat a higher percentage of calories from fat during her pregnancy? (LO 5.3) 8. Why not just “eat double” for a twin pregnancy? [Tables 5.13 through 5.17 and Figures 5.4 and 5.5 deal with aspects of a multifetal pregnancy.] (LO 5.4) 9. What are risks associated with an adolescent pregnancy? What messages could you develop to reach adolescents regarding each of these risks of pregnancy? (LO 5.7) [return to top]

ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. Compare Gestational Diabetes (LO 5.3) Total Time: 30 minutes

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 5: Nutrition During Pregnancy: Conditions and Interventions

Go to the Canadian Diabetes Association web site at www.diabetes.ca. Click on “Diabetes & You” and then scroll down to select “Gestational Diabetes” under the heading “What Is Diabetes?” Compare Canadian information on gestational diabetes with information from the U.S. government source NIH (http://www.nih.gov) or Ask-HRSA (https://www.hrsa.gov). How are weight gain recommendations similar or different? 2. Develop an assessment tool for gestational diabetes. (LO 5.3) Total Time: will vary Students should work together in pairs to develop an assessment tool for gestational diabetes. What would they need to include? (Weight status or overweight, physical activity levels, insulin resistance) 3. Using the Glycemic Index (LO 5.3) Total Time: 35 minutes Modify one day’s intake to lower the glycemic index. Have teams of two students interview each other about what was eaten in the last 24 hours. Pick one of the intakes to modify so that it includes more low- and moderate-glycemic index foods. Use foods that team members would actually eat. 4. Complete Worksheet 5-1: Type I Diabetes prior to Pregnancy (LO 5.3) Total Time: 20-30 minutes Answer Key: 1. Based on her most recent A1c level being in the normal range, Nan had good blood glucose control in the 120 days prior to the start of her pregnancy. 2. Yes: acesulfame potassium, aspartame, neotame, saccharin, and sucralose (ADA). 3. Fiber intake of 25–35 grams/day may decrease her need for insulin during pregnancy. She might also consider the application of the glycemic index in meal planning (Figure 5.2). Regular meal and snack consumption will be important to help her avoid hypoglycemia, and she might need slightly less carbohydrate at her morning meal than the other meals throughout the day due to the possibility of decreased carbohydrate tolerance in the morning (ADA). 4. Yes: for kidney disease and hypertension.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 5: Nutrition During Pregnancy: Conditions and Interventions

5. Complete Worksheet 5-2: Distribution of Calories for Gestational Diabetes (LO 5.3) Total Time: 20–30 minutes Answer Key: Food Item Serving Carbohydrates Fat Protein Calories Size (grams) (grams) (grams) Breakfast Complete Wheat ¾ cup 23 0.58 2.90 90 Bran Flakes 2% Milk ½ cup 6 2.42 4.03 61 Egg 1 1 10.61 12.58 74 Black coffee, tea Morning Snack Peanuts 2 oz 10 28.16 13.43 326 Carrot 1 7 0.15 0.57 31 Graham crackers 4 small 1.41 0.97 59 Lunch Beef or chicken 1 33 9.46 12.09 255 burrito Salsa ½ cup 7 0.22 1.99 33 Black beans 1 cup 40 0.93 15.24 228 Apple 1 21 0.31 0.47 81 Black coffee, tea, diet soda Midday Snack Banana ½ 28 0.39 1.29 55 2% milk 1 cup 12 4.83 8.05 121 Dinner Lean pork chop 4 oz 0 12.53 29.02 263 Pinto beans 1 cup 22 1.11 15.41 116 Corn bread 1 oz. 12 2.72 1.87 92 Margarine 1 tsp 1 3.78 0.04 33 Garden salad 2 cups 0 0.19 3.45 10 Feta cheese 1 oz 1 6.03 4.03 74 Salad dressing 2 Tbsp 3 10.52 0.33 104 Black coffee, tea, diet soda Bedtime Snack Peanut butter 2 Tbsp 12 16.12 8.03 190 Rice cake 1 8 0.25 0.74 35 2% milk 1 cup 12 4.83 8.05 121 Totals: — 270 2442 Calories: — 1080 117.55 144.58 2442 % of Total — 44% 43% 24% — Calories Recommendation — 40-50% 30-40% 20% —-

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 5: Nutrition During Pregnancy: Conditions and Interventions

Worksheet 5-1: Type I Diabetes prior to Pregnancy (LO 5.3) Nan has had type 1 diabetes for 15 years. Currently 29 years old and in the sixth week of her first pregnancy, she is referred to a registered dietitian for a review of nutrition recommendations for a healthy pregnancy. She brings her lab work with her, and it shows her last A1c level was obtained one month ago and was 5.5%. Nan is concerned that she won’t be able to use artificial sweeteners, and she asks if any have been found to be safe during pregnancy. A diet history shows a fairly high intake of processed foods. Her preferred meal planning method is carbohydrate counting, and she feels comfortable doing this already. Nan asks you for feedback on how she might be able to improve her diet. Questions: (To answer these questions, use the textbook and refer to the 2008 article “Nutrition Recommendations and Interventions for Diabetes: A Statement of the American Diabetes Association.” The reference is doi: 10.2337/dc08-S061; Diabetes Care, January 2008, vol. 31, no. Supplement 1, S61-S78; it is available at: http://care.diabetesjournals.org/content/31/Supplement_1/S61.full?ijkey=912502 4beb66755222a5f68f5a43ed6badcccc52&keytype2=tf_ipsecsha.)

1. How was Nan’s blood sugar control prior to pregnancy? How are you able to assess this?

2. Are there any artificial sweeteners that may be used safely during pregnancy?

3. What nutrition recommendations do you have for Nan during her pregnancy?

4. Is there a higher risk for complications due to having type 1 diabetes prior to pregnancy?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 5: Nutrition During Pregnancy: Conditions and Interventions

Worksheet 5-2: Distribution of Calories for Gestational Diabetes (LO 5.3) Use a food composition database (e.g., http://fdc.nal.usda.gov/fdc-app.html#/) to determine the amount of protein and fat in the 2400-calorie meal plan provided in Table 5.11, then determine how this compares to the recommendations for calorie distribution for gestational diabetes. Food Item Breakfast Complete Wheat Bran Flakes 2% milk Egg Black coffee, tea Morning Snack Peanuts Carrot Graham crackers Lunch Beef or chicken burrito Salsa Black beans Apple Black coffee, tea, diet soda Midday Snack Banana 2% Milk Dinner Lean pork chop Pinto beans Corn bread Margarine Garden salad Feta cheese Salad dressing Black coffee, tea, diet soda Bedtime Snack Peanut butter Rice cake 2% milk Totals: Calories: % of Total Calories

Serving Size

Carbohydrates (grams)

Fat (grams)

¾ cup

½ cup 1

6 1

61 74

2 oz 1 4 small

10 7

326 31 59

255

½ cup 1 cup 1

7 40 21

33 228 81

½ 1 cup

28 12

55 121

4 oz 1 cup 1 oz 1 tsp 2 cups 1 oz. 2 Tbsp

0 22 12 1 0 1 3

263 116 92 33 10 74 104

2 Tbsp 1 1 cup — — —

12 8 12 270

190 35 121 2442 2442 —

Protein (grams)

Calories

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 5: Nutrition During Pregnancy: Conditions and Interventions

Recommendation

—

40-50%

30-40%

20%

—-

[return to top]

ADDITIONAL RESOURCES INTERNET RESOURCES •

Science of nutrition o National Library of Medicine (PubMed): http://www.ncbi.nlm.nih.gov/pubmed o Academy of Nutrition and Dietetics Evidence Analysis Library: http://www.andeal.org/

•

Nutrition during pregnancy: conditions and interventions o American Diabetes Association: http://www.diabetes.org. Point to “About Diabetes” then select “Gestational Diabetes.” o Canadian Diabetes Association: http://www.diabetes.ca/. Click on “About Diabetes” and then scroll down to select “Gestational Diabetes.” Public food and nutrition programs o United States: National Institutes of Health National Institute of Child Health and Human Development: http://www.nichd.nih.gov. Search for information on gestational diabetes.

•

Nationwide priorities and nutrition al health o United States: Centers for Disease Control and Prevention, Pediatric and Pregnancy Nutrition Surveillance System (PedNSS): http://www.cdc.gov/pednss/index.htm

[return to top]

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 6: NUTRITION DURING LACTATION

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 5 Chapter Outline ................................................................................................................... 5 Discussion Questions.......................................................................................................... 9 Additional Activities and Assignments ............................................................................. 11 Additional Resources .........................................................................................................15 Internet Resources.................................................................................................................. 15

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to discuss the promotion efforts and greater understanding of the advantages of breastfeeding in the United States, and how these efforts have contributed to the resurgence of breastfeeding since the 1970s. This chapter discusses that multilevel (healthcare system, community, workplace, and family) support is critical for women who experience common breastfeeding challenges. In the last decade, gains were realized in both the initiation and duration of breastfeeding, but there is still a long way to go to reach the goal of exclusively breastfeeding for 4–6 months and continuing to breastfeed for at least a year to optimize health for women and children.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 6.1

Describe the development, the structure, and the functional components of the mammary gland. Describe the key hormonal influences on development and function.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

6.2

Identify similarities and differences in nutrient levels between colostrum and mature human milk, and between mature human milk, whole cow’s milk, and human milk substitutes (infant formula).

6.3

Summarize the benefits of breastfeeding/chestfeeding for mothers and their babies in a manner that could be included in breastfeeding education for pregnant mothers, their partners, and family members.

6.4

Generate an education plan for new mothers that includes the answers to common questions about milk supply, including what is typical milk production; what is the relationship between infant demand and maternal supply; and the influence of the size of the breast, feeding frequency, pumping, and breast surgeries on milk production.

6.5

Describe maternal steps to prepare the breast, and the basic position of the infant at the breast.

6.6

Describe infant behaviors that indicate readiness to feed, and vitamin supplement recommendations for breastfeeding/chestfeeding infants.

6.7

First, identify the professional and government sources of nutrient recommendations for healthy women for diet and supplements. Second, list common nutrition diagnoses for breastfeeding women, coupled with nutrition intervention and appropriate parameters for monitoring.

6.8

Identify at least two breastfeeding promotion programs that have demonstrated effectiveness at increasing breastfeeding initiation and duration.

6.9

Summarize factors known to be associated with higher and lower rates of breastfeeding, and the gap between current rates and the Breastfeeding Goals for the United States.

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KEY TERMS Mammary gland: The source of milk for offspring, also commonly called the breast. The presence of mammary glands is characteristic of mammals. Alveoli: A rounded or oblong-shaped cavity present in the breast. Secretory cells: Cells in the acinus (milk gland) that are responsible for secreting milk components into the duct.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

Myoepithelial cells: Specialized cells that line the alveoli and that can contract to cause milk to be secreted into the duct. Oxytocin: A hormone produced during letdown (natural reflex) that causes milk to be ejected into the ducts. Lobes: Rounded structures of mammary gland. Lactogenesis: Another term for human milk production. Mammogenesis: Another term for mammary growth. Galacopoiesis: Another term for maintenance of lactation following the establishment of lactation. Prolactin: A hormone necessary for milk production. Acinus: Small sacs lined by cells that produce milk. Exocytosis: The process by which the contents of vacuoles in the cell are carried to the exterior of the cell by fusing the membranes of the vacuole and the cell. Active transport: The flow of atoms, ions, or water from lower concentration to higher concentration. This process requires energy and is assisted by enzymes. Transcytosis: Transport of macromolecules across the interior of a cell. Macromolecules are captured in a sac from mother’s serum drawn across the cell and released into the milk ducts. Colostrum: The milk produced in the first 2–3 days after the baby is born. Colostrum is higher in protein and lower in lactose than milk produced after a milk supply is established. Isotonic: Similar salt concentration as the blood. Osmolality: A measure of the concentration of particles in solution. Human milk oligosaccharides (HMOs): Medium-length carbohydrates with nutritive and non-nutritive properties. Monovalent ion: An atom with an electrical charge of +1 or –1. Macrophages: A white blood cell that acts mainly through phagocytosis. Neutrophils: Class of white blood cells that are involved in the protection against infection. T-lymphocyte: A white blood cell that is active in fighting infection. (May also be called T-cell; the T in T-cell stands for thymus.) These cells coordinate the immune system by secreting hormones that act on other cells.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

B-lymphocytes: White blood cells that are responsible for producing immunoglobulins. Epithelial cells: Cells that line the surface of the body. Secretory immunoglobin A (slgA): A protein found in secretions that protect the body’s mucosal surfaces from infections. The mode of action may be by reducing the binding of a microorganism with cells lining the digestive tract. It is present in human colostrum but not transferred across the placenta. Morbidity: The rate of illnesses in a population. Mortality: Rate of death. Cognitive function: The process of thinking. Doula: An individual who surrounds, interacts with, and aids the mother at any time within the period that includes pregnancy, birth, and lactation; may be a relative, friend, or neighbor and is usually but not necessarily female. One who gives psychological encouragement and physical assistance to a new mother. Innocenti Declaration: On the Protection, Promotion, and Support of Breastfeeding: Policy statement adopted by participants at the World Health Organization/UNICEF policymakers’ meeting on breastfeeding, a global initiative held in Italy in 1990. The policy established exclusive breastfeeding from birth to 4–6 months of age as a global goal for optimal maternal and child health. Lactation consultant: Healthcare professional whose scope of practice is focused on providing education and management to prevent and solve breastfeeding problems and to encourage a social environment that effectively supports the breastfeeding mother and infant. Those who successfully complete the International Board of Lactation Consultant Examiners (IBLCE) certification process are entitled to use the IBCLC (International Board Certified Lactation Consultant) after their names (http://www.iblee.org). La Leche League: International, nonprofit, nonsectarian organization dedicated to providing education, information, support and encouragement to women who want to breastfeed. Founded in 1956 by seven women who had learned about successful breastfeeding while nursing their own babies, it currently has over 5000 leaders in over 80 countries on every continent except Antarctica. Accredited lay leaders facilitate mother-to-mother meetings around the world. These meetings moved online due to the coronavirus pandemic to continue to provide breastfeeding support to mothers. (http://www.lalecheleague.org). [return to top]

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • • • • • • • • • • • • • • •

Updated breastfeeding information Updated DRI for energy during lactation New chart on nutritional components of mammal milk Strengthened section on colostrum, including updated data on composition of colostrum and mature milk Expanded section on growth in the breastfed infant Expanded information on cholesterol in human milk Added key term human milk oligosaccharide Strengthened vitamin D section Expanded section on breastfeeding benefits for women Expanded section on presenting the breast to the suckling infant Strengthened section on infant colic Updated the Healthy People 2030 objectives for breastfeeding Added information on the Texas 10-step program Expanded section on baby-friendly hospital practices and updated mPINC indicators associated with the 10 steps for successful breastfeeding Added information on Model Breastfeeding promotion programs Updated Centers for Disease Control and Prevention (CDC) breastfeeding report card data information, including the rates of any and exclusive breastfeeding table

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CHAPTER OUTLINE I.

Introduction a. The benefits for mothers and infants are well established. b. Breastfeeding rates have been increasing since the 1970s, but duration is relatively stable. c. Communities play an important role; they can facilitate or hinder breastfeeding.

II. Lactation Physiology Describe the development, the structure, and the functional components of the mammary gland. Describe the key hormonal influences on development and function. (LO 6.1) a. Three illustrations (6.1, 6.2, and 6.3) help to explain the process of milk production and secretion.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

b. An understanding of the effects of nutrition, medications, and disease on breastfeeding is based on the five pathways of milk secretion shown in Figure 6.3. c. This section offers an opportunity to connect hormonal controls of breast development from previous chapters to Chapter 6; see Table 6.1 on hormones contributing to lactation. d. The stages of lactogenesis and the letdown reflex are also explained. III. Human Milk Composition Identify similarities and differences in nutrient levels between colostrum and mature human milk, whole cow’s milk, and human milk substitutes (infant formula). (LO 6.2) a. The section on human milk composition is sizable, and the discussion of casein versus whey can help to explain that not all proteins are created equal. b. The majority of healthy infants need no food besides human milk for approximately 6 months. c. Many factors affect the composition of human milk, including length of gestation at delivery, the infant’s age, presence of infection at the breast, menses, and maternal nutritional status. d. The approximate composition of colostrum is provided in Table 6.3 and that of human milk is listed in Table 6.4; human milk is lower in protein than other mammalian milks. e. The mother’s fat intake affects the lipid profile of her milk, but not the fat content; exposure to sunlight affects vitamin D content. f. The bioavailability of several minerals (iron, calcium, magnesium, and zinc) is higher in human milk than cow’s milk. g. Maternal diet affects the taste of milk; infants respond to variations in the taste of milk, preferring new tastes. IV. Benefits of Breastfeeding Summarize the benefits of breastfeeding/chestfeeding for mothers and their babies in a manner that could be included in breastfeeding education for pregnant mothers, their partners, and family members. (LO 6.3) a. Women experience hormonal, physical, and psychological benefits from breastfeeding. b. Human milk substitutes use human milk as their standard. c. The attributes of human milk match the needs of newborn growth and development. d. In addition to the nutritional benefits, infants gain immunological, health (measured by reduced morbidity rates), and cognitive benefits. e. Analgesic effects are seen when infants are breastfed during venipuncture, heel pricks, and minor invasive procedures.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

V. Breast Milk Supply and Demand Generate an education plan for new mothers that includes the answers to common questions about milk supply, including what is typical milk production; what is the relationship between infant demand and maternal supply; and the influence of the size of the breast, feeding frequency, pumping, and breast surgeries on milk production. (LO 6.4) a. Milk production can range from 450 to 1200 mL/day for women nursing a single infant. b. The rate of milk synthesis is related to infant demand. c. The size of a breast does not determine the amount of milk produced, although it affects the amount of milk that a lactating woman can store. d. It’s recommended to nurse the infant (or pump) early and often to build a good milk supply. e. Safe breastfeeding can occur after surgery and also with silicone implants. VI. The Breastfeeding Process Describe maternal steps to prepare the breast, and the basic position of the infant at the breast. (LO 6.5) a. The breast needs to be prepared for nursing a child; several positions for breastfeeding are described and illustrated in Figure 6.4. VII. The Breastfeeding Infant Describe infant behaviors that indicate readiness to feed, and vitamin supplement recommendations for breastfeeding/chestfeeding infants. (LO 6.6) a. Some of the issues addressed in this section are reflexes, identifying hunger and satiety, mechanics of breastfeeding, frequency of feeding, supplements, identifying malnutrition, tooth decay, and straighter teeth due to the development of a well-rounded dental arch. VIII.

Maternal Diet First, identify the professional and government sources of nutrient recommendations for healthy women for diet and supplements. Second, list common nutrition diagnoses for breastfeeding women, coupled with nutrition intervention and appropriate parameters for monitoring. (LO 6.7)

a. The USDA Food Patterns/MyPlate website now can be used to get dietary recommendations for women who are breastfeeding. b. The DRIs for lactating women for weight maintenance and weight loss are discussed. c. Multiple mechanisms are engaged to provide an adequate milk supply to the infant; lactating women adjust both energy intake and activity levels.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

d. Although inadequacies are seen in the vitamin and mineral intakes of lactating mothers, there are no reports of deficiencies and there are no recommendations for supplements for all breastfeeding women. e. Careful balance is needed between concern for inadequate maternal diets and discouraging women from breastfeeding. f. Postpartum weight loss, calculated at 0.8 kg per month, is inconsistent and smaller than expected; average weight loss during breastfeeding is larger in affluent countries than in underprivileged populations. g. There seems to be a threshold effect for caloric intake: while small deficiencies in energy do not affect milk output, large calorie deficiencies decrease milk supply. h. Weight loss during lactation can be accomplished without sacrificing the quality of the maternal diet; careful attention is needed to the intakes of calcium and vitamin D. i. Vigorous exercise does not lead to declining milk production. j. Milk composition responds to maternal intake of nutrients; for instance, lack of vitamin D in the mother can lead to deficiencies in the infant. k. Mothers with special dietary needs (e.g., avoidance of certain food groups, following an alternative diet) can benefit from nutritional counseling and nutritional supplementation.

IX. Public Food and Nutrition Programs Identify at least two breastfeeding promotion programs that have demonstrated effectiveness at increasing breastfeeding initiation and duration. (LO 6.8) a. One of the ways that national policy is implemented is through the WIC program, which funds breastfeeding promotion as a part of its services. b. WIC funds can be used to provide supplemental foods and aids such as breast pumps to breastfeeding women. X. Optimal Duration, Influential Factors, and U.S. Goals for Breastfeeding Summarize factors known to be associated with higher and lower rates of breastfeeding, and the gap between current rates and the Breastfeeding Goals for the United State. (LO 6.9) a. A common question about breastfeeding relates to optimal duration; “health benefits to the mother–child pair should be the primary criteria” used to decide this question. b. The consensus among experts is that infants should exclusively be breastfed for their first 6 months due to the many health benefits it provides. c. As human milk substitutes (HMS) appeared on the market, breastfeeding rates declined to below 30% during the 1950s and 1960s.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

d. National objectives in Healthy People 2030 focus on increasing both the proportion of infants exclusively breastfed though 6 months as well as the duration of breastfeeding at 1 year. e. There is significant variation in BF rates geographically and among racial and ethnic groups. f. Rates are lowest in African American women. XI. Breastfeeding Promotion, Facilitation, and Support a. Supportive environments and actions of family, community, workplace, the healthcare sector, and society are key to successful breastfeeding. b. Table 6.9 summarizes an effective counseling strategy developed by Best Start Social Marketing. c. The Innocenti Declaration is a statement of international commitment made through WHO/UNICEF to protect, promote, and support breastfeeding. d. Figure 6.7 and Tables 6.8 and 6.10 describe hospital practices that support breastfeeding. e. Companies and Table 6.14 can be used to discuss key elements of workplace support of employees who are breastfeeding. f. Table 6.15 lists public policy documents that highlight the national commitment to breastfeeding promotion. XII. Model Breastfeeding Promotion Programs a. Social marketing techniques have been effective in raising rates of breastfeeding. b. Evaluation studies have shown that efforts to increase breastfeeding rates, such as those by WIC together with Best Start Social Marketing and by Wellstart International, are working. [return to top]

DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class. 1. Breastfeeding rates are still low (Table 6.6), so some students may not have had any experience seeing an infant being breastfed. What are students’ personal experiences related to breastfeeding? Have their perceptions of breastfeeding been affected by reading about the benefits of breastfeeding in class or from consumer literature? To expand on one of the Lecture Launchers: What percentage of the class knows whether they were or were not breastfed? If they were breastfed, what was the duration? (LO 6.9)

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

2. Human milk composition matches the needs of growing infants. How could you use this information and one of the other benefits of breastfeeding to generate convincing strategies that would persuade your peers to breastfeed? (LO 6.2) 3. What are the contributions colostrum makes to an infant’s healthy start in life? The components of colostrum and amounts consumed by a newborn are discussed in this chapter. Estimate how many calories from colostrum are ingested by a newborn. (LO 6.2) 4. If breastfed infants develop more cognitive power and stay healthier, why isn’t every infant breastfed? How do the Healthy People 2030 objectives compare to the highest rate of breastfeeding (in the early 1900s) and to the lowest rates (in the 1950s and 1960s)? [See Tables 6.6 and 6.7.] What is a global goal? [Innocenti Declaration] (LO 6.9 and 6.10) 5. A common misconception is that women with small breasts cannot produce sufficient milk to support infant growth. What is true about breast size as it relates to breastfeeding? What are the determinants of how much milk a woman can make? (LO 6.4) 6. Discuss the roles of prolactin and oxytocin in enabling lactation. Can a woman’s lifestyle or behavior affect hormonal expression? [Yes, for example, stress] What are strategies to enhance the let-down reflex? Folk wisdom sometimes suggests drinking beer will enhance milk production and let-down. What do you think about this? (LO 6.1) 7. Discuss the implications of Table 6.14 (Worksite Lactation Support). (LO 6.10) a. Ask students to generate workplace strategies or policies that could support lactation. b. Compare these suggestions with Table 6.14. Ask students to think about the places they’ve worked and whether the environment facilitated breastfeeding or not. They might not have been aware of either supportive or hindering policies; use Table 6.14 to stimulate dialogue. 8. What do you think about the WHO/UNICEF Code on the marketing of breast milk substitutes (Table 6.11)? (LO 6.10) 9. The profiles of a low-income and an affluent pregnant woman highlight society’s role in promoting successful breastfeeding. What can a community do to promote breastfeeding at all income levels? Is it appropriate that the WIC program spends part of its budget on breastfeeding promotion? (LO 6.10) [return to top]

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. Have a Debate (LO 6.10) Total Time: 30 minutes Divide the class into two groups. Have the students debate the topic of “Should insurance companies give discounted rates to infants and children who have been breastfed?” Allow students 15 minutes to discuss their key points within their group and then give each group 7 minutes and 30 seconds to defend their opinions. 2. Potential Barriers to Successful Breastfeeding (LO 6.10) Total Time: 35–40 minutes As a class, generate a list of potential barriers to successful breastfeeding, or use those in the text, for example, in Figure 6.8. Break up the class into small teams and assign a barrier or two to each team. Have each team generate 2–3 strategies that would deal with each barrier. Teams report back to the class. Summarize by integrating text examples (e.g., Baby-Friendly Hospital in Table 6.12, worksite support in Table 6.14) with student-generated strategies. 3. Poor Milk Production (LO 6.4) Total Time: 30 minutes Which dietary factors lead to poor production of milk (quantity and quality)? Break up the class into small groups. Have each group devise a list of questions to assess a mother’s diet relative to her needs for breastfeeding a 3-month-old infant. After 10 minutes of group work, ask each team to report their list and write the nutrients mentioned on a transparency. Add to the list as new groups clarify and complete the list. When there are no more additions, ask the class for foods that contain the needed nutrients (do this for a few categories) and supplement the list with strategies to ensure adequate milk production. 4. Baby-Friendly Hospital Initiative (LO 6.10) Total Time: 30 minutes Table 6.12 describes 10 steps to successful breastfeeding that make up the BabyFriendly Hospital Initiative. Assign small groups to selected steps and have them generate approaches to implementing their step in a hospital. What are potential barriers? How does implementation of these steps accommodate various cultural beliefs and values? 5. Complete Worksheet 6-1: Case Study—Maternal Weight Loss During Breastfeeding (LO 6.7) Total Time: 20–30 minutes Answer Key: 1. Sheila could possibly lose weight with a reduction in her calorie intake of 500 kcalories per day, focusing on reducing her intake of sugary and high-fat foods. Based on her current estimated calorie intake level of 2700 kcalories, an estimated daily calorie need would be 2200 kcalories. 2. 1500 kcalories

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

3. With her limited intake of fruits, vegetables, and dairy, she might be having difficulty consuming adequate levels of vitamins A, C, and D and calcium. Fruits, vegetables, and low-fat or fat-free dairy products should be encouraged with the possible addition of a daily multivitamin with minerals. 4. Increasing her daily physical activity level within her physician’s guidelines for her. 5. If her daughter is producing approximately 6 wet diapers and 3–4 soft yellowish stools per day and continues to gain weight appropriately, Sheila can continue her regimen. 6. Complete Worksheet 6-2: The Nutrition of Colostrum and Human Milk (LO 6.2) Total Time: 20–30 minutes Answer Key: 1. 120 mL × (55 kcal/100 mL) = 66 kcal 2. 120 mL × (2.0 g/100 mL) = 2.4 g protein 3. 120 mL × (151 µg RAE/100 mL) = 181.2 µg RAE 4. 120 mL × (28 mg/100 mL) = 33.6 mg calcium 5. 750 mL × (67 kcal/100 mL) = 502.5 kcal 6. 750 mL × (1.1 g/100 mL) = 8.25 g protein 7. 750 mL × (75 µg RAE/100 mL) = 562.5 µg RAE 8. 750 mL × (30 mg/100 mL) = 225 mg calcium

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

Worksheet 6-1: Case Study—Maternal Weight Loss During Breastfeeding (LO 6.7) Sheila, 32 years old, has been referred to a registered dietitian following her 6-week postpartum check-up following her third pregnancy, as she has concerns about her goals of weight loss and still being able to meet her daughter’s nutritional needs through breastfeeding. This pregnancy was complicated by gestational diabetes, as was her second pregnancy. She gained 37 lb and states an understanding of the need to lose her pregnancy weight to reduce the risk of developing type 2 diabetes. She wasn’t successful with losing the weight from her second pregnancy. Her daughter was 9 pounds 11 ounces at birth and has been gaining weight appropriately. Sheila breastfed her first two children until they were approximately 5 months old. Her current weight is 223 lb, and her height is 5 feet 5 inches. She reports she hasn’t started exercising yet, but she was medically cleared to do so by her physician. Sheila’s 24-hour recall shows an estimated calorie intake of 2700 kcal with limited fruits and vegetables, one cup of milk, and portions of high-fat and sugary foods. She has been maintaining her weight with her current calorie intake.

Questions: 1. What is an estimated daily calorie intake that would allow Sheila to lose weight?

2. What daily calorie intake would be considered too low to support breast milk production?

3. Are there any vitamins and minerals Sheila might have inadequate intakes of based on her 24-hour recall? How would you recommend she adjust her food intake to meet her needs for these nutrients?

4. What other recommendations do you have for Sheila to assist with her weight loss goals?

5. How will Sheila know whether her daughter is receiving adequate nutrition while she focuses on her goal of weight loss while breastfeeding?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

Worksheet 6-2: The Nutrition of Colostrum and Human Milk (LO 6.2) Directions: Complete the following worksheet using the data available in Table 6.3.

1. What is the calorie content of 120 mL of colostrum?

2. What is the protein content of 120 mL of colostrum?

3. What is the vitamin A content of 120 mL of colostrum?

4. What is the calcium content of 120 mL of colostrum?

5. What is the calorie content of 750 mL of human milk?

6. What is the protein content of 750 mL of human milk?

7. What is the vitamin A content of 750 mL of human milk?

8. What is the calcium content of 750 mL of human milk?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

ADDITIONAL RESOURCES INTERNET RESOURCES INTERNET RESOURCES ●

General nutrition o

●

Public food and nutrition programs o o

●

o o o

2022 Breastfeeding Report Card: http://www.cdc.gov/breastfeeding/data/reportcard.htm Title V Maternal and Child Health programs of the Health Resources and Services Administration: http://www.mchb.hrsa.gov Centers for Disease Control and Prevention: http://www.cdc.gov Breastfeeding Legislation and Policy: http://www.usbreastfeeding.org/active-legislation.html

Lactation support o o o o o o

●

WIC Works website supported by the USDA Food and Nutrition Information Center: https://wicbreastfeeding.fns.usda.gov Farmers Market Nutrition Program: http://www.health.ny.gov/prevention/nutrition/fmnp/

Nationwide priorities and nutritional health o

●

USDA Food Patterns/MyPlate: http://www.choosemyplate.gov/pregnancy-breastfeeding.html

U.S. Breastfeeding Committee: http://www.usbreastfeeding.org Academy of Breastfeeding Medicine: http://www.bfmed.org Baby-Friendly USA Hospital Initiative: http://www.babyfriendlyusa.org/ International Board Certified Lactation Consultants: http://www.iblce.org La Leche League: https://llli.org/ Business Case for breastfeeding created by Office of Women’s Health: http://womenshealth.gov/breastfeeding/breastfeeding-home-workand-public/breastfeeding-and-going-back-work/business-case

Science of nutrition o

National Library of Medicine (PubMed): http://www.ncbi.nlm.nih.gov/pubmed

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 6: Nutrition During Lactation

●

Public food and nutrition programs o o

●

UNICEF Baby-Friendly Hospital Initiative: http://www.unicef.org/documents/baby-friendly-hospital-initiative WIC Works Resource System of health and nutrition professionals: http://wicworks.fns.usda.gov

Nationwide priorities and nutritional health o o o

●

Eating Well with Canada’s Food Guide: http://www.hc-sc.gc.ca/fnan/food-guide-aliment/index-eng.php

Breastfeeding Policy: http://pediatrics.aappublications.org/content/129/3/e827.short U.S. Department of Agriculture, Women, Infants, and Children (WIC) Program: http://www.fns.usda.gov/wic Canada—Public Health Agency of Canada (A Practical Workbook to Protect, Promote and Support Breastfeeding in Community Based Projects): http://www.phac-aspc.gc.ca/hp-ps/dcadea/publications/ppsb-ppsam-eng.php

Lactation nutrition o o o o o

Bright Future Lactation Resource Center: https://bflrc.org International Lactation Consultation Association: http://www.ilca.org Lactation Education Resources: http://www.lactationtraining.com National Center for Education in Maternal and Child Health: http://www.ncemch.org Wellstart International: http://www.wellstart.org/

[return to top]

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 7: Nutrition During Lactation: Conditions and Interventions

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 7: NUTRITION DURING LACTATION: CONDITIONS AND INTERVENTIONS

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 3 Chapter Outline ................................................................................................................... 4 Discussion Questions.......................................................................................................... 7 Additional Activities and Assignments .............................................................................. 8 Additional Resources .........................................................................................................13 Internet Resources.................................................................................................................. 13

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to discuss prevention and treatment of common breastfeeding/chestfeeding conditions. Important considerations for breastfeeding multiples, preterm infants, and infants with medical problems are discussed. The chapter concludes with case studies providing examples of management of challenging breastfeeding problems and with examples of model programs promoting support for breastfeeding in the healthcare system.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 7.1

List at least five common breastfeeding/chestfeeding conditions.

7.2

Associate positive and negative impacts of maternal medications on mother’s/lactating persons’ breast milk.

7.3

List two examples of herbal galactogogues used during lactation.

7.4

Describe the impact of marijuana on mother’s/lactating persons’ breast milk.

7.5

Explain causes of hyperbilirubinemia and ways to prevent kernicterus.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 7: Nutrition During Lactation: Conditions and Interventions

7.6

Identify ways health professionals can help the mother of multiples face the challenges of breastfeeding/chestfeeding.

7.7

Distinguish between food allergy and food intolerance.

7.8

Identify at least three factors that contribute to increased readmission rates for late-preterm infants.

7.9

List three benefits of human breast milk for premature infants.

7.10

Demonstrate knowledge of medical contraindications to breastfeeding/chestfeeding.

7.11

List three guidelines for storage of human milk for home use.

7.12

Analyze one of the model programs for breastfeeding promotion in the United States.

KEY TERMS Ankyloglossia (tongue-tie): A congenital condition of a tight or short frenulum that causes tongue restriction and range of motion. Milk bleb/milk blister: A tender inflammatory area sealed off by the epidermis on the nipple that is white or yellow area. Galactogogue: A medicine or herbal substance taken with the belief to increase milk supply. It may also be taken to help with breastmilk initiation and maintenance. Milk/plasma ratio: The ratio of the concentration of drug in milk to the concentration of drug in maternal plasma. Since the ratio varies over time, a time-averaged ratio provides more meaningful information than data obtained at a single time point. It is helpful in understanding the mechanisms of drug transfer and should not be viewed as a predictor of risk to the infant, as it is the concentration of the drug in milk, and not the M/P ratio, that is critical to the calculation of infant dose and assessment of risk. Exposure index: The average infant milk intake per kilogram body weight per day × (M/P ratio ÷ Rate of drug clearance) × 100. It is indicative of the amount of the drug in the breast milk that the infant ingests and is expressed as a percentage of the therapeutic (or equivalent) dose for the infant. Medicinal herbs: Plants used to prevent or remedy illness. Persistent organic pollutants (POPs): A family of chemicals manufactured either for a specific purpose (e.g., pesticides or flame retardants in electrical equipment or furniture) or produced as byproducts of incinerated waste. The POP family includes

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 7: Nutrition During Lactation: Conditions and Interventions

dioxins, polychlorinated biphenyls (PCBs), polybrominated diphenyl ether (PBDE), and organochlorine pesticides. Per- and polyfluoroalkyl substances (PFAS): A family of man-made chemicals used in stain resistant fabrics, non-stick cookware, products that resist water, grease, oil, some cosmetics, and water-repellent clothing. Hyperbilirubinemia: Elevated blood levels of bilirubin, a yellow pigment that is a byproduct of the breakdown of fetal hemoglobin. Bilirubin encephalopathy or kernicterus: The chronic and permanent clinical sequelae that are the end result of very high untreated bilirubin levels. Excessive bilirubin in the system is deposited in the brain, causing toxicity to the basal ganglia and various brainstem nuclei. Meconium: Dark green mucilaginous material in the intestine of the full-term fetus. Allergic diseases: Conditions resulting from hypersensitivity to a physical or chemical agent. Food allergy (hypersensitivity): Abnormal or exaggerated immunologic response, usually immunoglobulin E (IgE) mediated, to a specific food protein. Food intolerance: An adverse reaction involving digestion or metabolism but not the immune system. HIV: Human immunodeficiency virus

WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • • • • • • • • • • •

Expanded section on flat/inverted nipples New section on small and large nipples New key term: milk bleb/milk blister New term: chestfeeding/breastfeeding Expanded section on hyperlactation Updated mastitis section Strengthened section on domperidone use Strengthened section on use of galactagogues New section on e-cigarettes Expanded section on marijuana New section on methadone Updated information on multiple births and neonatal intensive care unit (NICU) stay on breastfeeding

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 7: Nutrition During Lactation: Conditions and Interventions

• • •

New information on the impact of the COVID-19 pandemic on breastfeeding support Strengthened section on colic and food intolerances Expanded model programs to include the Hear Her Campaign

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CHAPTER OUTLINE I.

Introduction a. “The vast majority of women do not experience significant problems with breastfeeding.” b. The prevention and treatment of common breastfeeding conditions is covered in this chapter.

II. Common Breastfeeding Conditions List at least five common breastfeeding/chestfeeding conditions. (LO 7.1) a. This section covers sore nipples (some pain is normal, while severe pain is not), flat or inverted nipples, letdown failure (six points to enhance letdown), hyperactive letdown (can lead to a fussy baby; prevent overactive letdown by expressing some milk, then feeding hindmilk), hyperlactation, engorgement (peak time is in first 2 weeks; nurse frequently), plugged duct (massage, compresses), mastitis (early treatment), and low milk supply. b. Table 7.1 describes symptoms of the main problems faced in breastfeeding. III. Maternal Medications Associate positive and negative impacts of maternal medications on mother’s/lactating persons’ breast milk. (LO 7.2) a. Most medications are excreted in breast milk, and data on safety isn’t readily available. b. The AAP committee on drugs publishes guidelines for health care providers based on classifications of drugs in seven risk-based categories, from contraindicated drugs to “foods and environmental agents having no effect on breastfeeding.” The AAP updates these guidelines. They are considered reliable because the AAP’s list is not sponsored by drug firms (whose decisions are guided by different legal concerns). c. Table 7.2 provides resources on drugs, medications, and contaminants in human milk. d. Table 7.3 provides tips for minimizing the effects of maternal medications. e. Oral contraceptives are covered in this section. IV. Herbal Remedies List two examples of herbal galactogogues used during lactation. (LO 7.3)

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 7: Nutrition During Lactation: Conditions and Interventions

a. Review Table 7.4 for herbs traditionally used to affect milk production and Table 7.5 for herbs to avoid. b. Table 7.6 lists teas classified as safe. c. Because herbs and breastfeeding are often linked in folk history, herbal use during lactation can serve as an opportunity to clarify herbal usage. d. Issues to examine include which part of the plant has been tested as safe, which form of the herb is ingested, and what strength or dosage has been shown to be beneficial. e. The relationships among culinary herbs and medicinal herbs can help to make the point that sometimes too much of a good thing is not a good thing. f. The herbs covered in depth include Echinacea, ginseng root, St. John’s wort, fenugreek, goat’s-rue, and milk thistle/blessed thistle (cabbage leaves are covered in the engorgement section). V. Alcohol and Other Drugs and Exposures Describe the impact of marijuana on mother’s/lactating persons’ breast milk. (LO 7.4) a. Alcohol, nicotine (cigarette smoking), marijuana, caffeine, other drugs of abuse, and environmental exposures are covered in this section. VI. Neonatal Jaundice and Kernicterus Explain causes of hyperbilirubinemia and ways to prevent kernicterus. (LO 7.5) a. Bilirubin is a cell toxin naturally produced when hemoglobin breaks down; unresolved hyperbilirubinemia (excessive amounts of bilirubin in the blood) can lead to permanent neurological damage. b. Jaundice is common in newborns, but is more common and more serious in premature infants. c. Physiologic jaundice is distinguished from pathologic jaundice, which begins earlier, rises faster, and lasts longer. d. The comparison of jaundice related to breast-nonfeeding and breastmilk is covered in Table 7.10, and strategies for preventing and managing jaundice are addressed in Table 7.11. e. “Continued and frequent breastfeeding (at least eight to twelve times every 24 hours)” is recommended by the AAP in cases of hyperbilirubinemia; passing the meconium prevents some reabsorption of bilirubin. VII. Breastfeeding Multiples Identify ways health professionals can help the mother of multiples face the challenges of breastfeeding/chestfeeding. (LO 7.6) a. Evidence from history (such as wet nurses in foundling homes) and from case reports supports successful breastfeeding of multiples.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 7: Nutrition During Lactation: Conditions and Interventions

b. Frequent and effective breastfeeding establishes the milk supply, which can be as much as 2 to 3 kilograms per day. c. A varied and well-balanced diet provides needed nutrients. VIII.

Infant Allergies Distinguish between food allergy and food intolerance. (LO 7.7)

a. One of the most important benefits of breastfeeding is protection from allergic diseases. b. Common pediatric allergens are listed on p. 210. c. Definitions for food allergy and food intolerance help students distinguish between them and understand the prevalence of true food allergies. d. Reasons why breastfeeding may be protective against allergies are listed in Table 7.12. IX. Late-Preterm Infants Identify at least three factors that contribute to increased readmission rates for late-preterm infants. (LO 7.8) a. Infants born at 34 to 37 weeks may have more difficulty establishing breastfeeding. b. Strategies for successful breastfeeding in late preterm infants are discussed. c. The late-preterm infant breastfeeding cascade is shown in Figure 7.1. X. Human Milk and Preterm Infants List three benefits of human breast milk for premature infants. (LO 7.9) a. Human milk promotes the health of the preterm infant better than formula; however, supplementation with vitamins C, D, E, and K as well as protein, calcium, phosphorus, magnesium, sodium, copper, zinc, riboflavin, pyridoxine, and folic acid via human milk fortifiers is necessary once growth is established. b. The milk composition in mothers of preterm infants is different than that available to full-term infants. c. Early feeding is recommended for premature infants. d. Milk supply can be increased through milk expression or pumping. e. Strategies to improve breastfeeding rates in preterm infants are discussed. XI. Medical Contraindications to Breastfeeding Demonstrate knowledge of medical contraindications to breastfeeding/chestfeeding. (LO 7.10) a. Shall I breastfeed or not? Few conditions make breastfeeding unsafe: “There are very few infectious pathogens that pose a risk to the newborn that outweighs the potential benefits of breastfeeding.”

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 7: Nutrition During Lactation: Conditions and Interventions

b. HIV infection of the mother is the most common contraindication, and transmission of AIDS/HIV ranges from 5% to 20% and increases to 35% to 40% with prolonged duration of breastfeeding. c. World Health Organization guidelines consider economic status in their guidance statements. XII. Human Milk Collection and Storage List three guidelines for storage of human milk for home use. (LO 7.11) a. The Human Milk Banking Association of North America makes milk available through prescriptions and has published evidence-based guidelines for the collection and storage of human milk. b. Milk handling is guided by rules similar to blood banking (donors are screened, fluids are tested). c. Milk banks in North America are scarce, but demand for human milk is increasing. XIII. Model Programs Analyze one of the model programs for breastfeeding promotion in the United States. (LO 7.12) a. Success stories motivate and guide replication. b. Breastfeeding is promoted by group education and support programs such as the Rush Mothers’ Milk Club. [return to top]

DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class. 1. This statement introduces Chapter 7: “The vast majority of women do not experience significant problems with breastfeeding.” What do you consider “the vast majority”? Provide specific information that supports this statement. (Introduction) 2. We know that alcohol levels in breast milk reflect those in the maternal blood. You are asked to comment on alcohol use during lactation. How would you advise a healthy woman who is breastfeeding a normally growing infant? How would this advice change if the infant were colicky and had trouble sleeping? (LO 7.4) 3. Early jaundice is common in newborns. How is jaundice diagnosed? How can you distinguish between “normal” jaundice that will go away and jaundice needing

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 7: Nutrition During Lactation: Conditions and Interventions

treatment? What effect does stoppage of breastfeeding have on the infant’s jaundice? (LO 7.5) 4. Review Tables 7.4 and 7.5: What other information would you want to know in relation to the herbs listed before applying this information? To take this one step further: Go to your grocery store and see how many of these items you can locate. Does the label on any of these products indicate a relationship to milk production? (LO 7.3) 5. If the nutritional content of milk changes according to infant need, how can a milk banking system accommodate these varied needs? What other options are there for feeding an infant with human milk when the mother is unavailable to do so? What do students know about wet nurses? Are they more prevalent in some (ethnic) population groups? (LO 7.11) 6. Although milk is the only food needed for healthy infant development up to the age of 6 months, preterm infants benefit from vitamin supplements. Which vitamins are supplemented? When is it not necessary to supplement with vitamin D? (LO 7.9) 7. If you were developing a breastfeeding promotion kit for physicians and other health care providers in your community, what would you put into it? What would the kit include for the families with new infants? (LO 7.12) 8. Review Table 7.7. What is the relationship between body weight and alcohol clearance in breast milk? Why does the alcohol content of breast milk reach “0” faster in heavier than in lighter women? What are the benefits and drawbacks of moderate alcohol use in lactating women? (LO 7.4) 9. Page 196 of the text suggests that “The Physician’s Desk Reference (PDR) is not a good source for information about drugs and breastfeeding because the information is derived directly from pharmaceutical companies whose first concern is avoiding liability.” Take a stance of either agreeing or disagreeing with this statement and discuss your reasoning. (LO 7.2) [return to top]

ADDITIONAL ACTIVITIES AND ASSIGNMENTS I.

Practicing Writing a Grant (LO 7.12) Total Time: 35 minutes You are asked to write a 1-page (single-spaced) section on the benefits of breastfeeding high-risk infants for a grant application that would institute a mothers’ milk club (like the Rush program, pp. 210–211) in a major medical center. Some questions to get you started with the application: What are the benefits of breastfeeding to high-risk infants? What cost/budget information would you need to ask for? Based on the text, what makes the Rush Mothers’

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 7: Nutrition During Lactation: Conditions and Interventions

Milk Club a success story? Will you also include families in the “mothers’ club”? II. Breastfeeding Case Scenario (LO 7.1) Total Time: 40 minutes Many conditions and interventions related to breastfeeding are more environmentally related than physiological. Hand out the following case scenario: A mom who delivered a preterm infant wanted to pump breast milk while working during the day; however, her employer provided neither a private area nor equipment. She submitted a request to establish a breastfeeding room and asked that the company purchase a Professional Medela Pump at a cost of $260. The president of Company XYZ refused, stating that single working individuals would have equal rights to a “private room” and the cost of the pump was unreasonable. He also stated that the new mom would be less stressed if she didn't have to worry about breastfeeding. The new mom had worked for Company XYZ for 12 years and had excellent health care insurance covering the preterm baby's stay in the neonatal intensive care unit (NICU). The mom felt she was being taken advantage of. Have students role play the confrontation. What are the new mom's rights? Take a vote: how many students feel the company should purchase the breastfeeding pump?

III. Creating a Breastfeeding Fact Sheet (LO 7.1) Total Time: 30 minutes Go to the La Leche League International website to explore the subject of sore nipples at: https://www.llli.org/breastfeeding-info/breastfeeding-sore-nipples/ What is normal soreness, and what is problematic enough to treat? Compare the answers you get with those of the text and develop a fact sheet for women who are starting to breastfeed. IV. Complete Worksheet 7-1: Case Study—The Use of Medical Herbs, Nutrition Supplements, and Medications During Breastfeeding (LO 7.3) Total Time: 20–30 minutes Answer Key: 1. See Table 7.2 for ideas. 2. Her physician first and foremost, a referral to a registered dietitian, and the resources listed in Table 7.2. Also, www.diabetes.org 3. Echinacea should be avoided (Table 7.5). 4. Methyldopa would be fine to continue (http://toxnet.nlm.nih.gov/cgibin/sis/search2), and the herbal teas listed in Table 7.6 would be fine to continue. As for metformin, lisinopril, cinnamon, and fish oils, she should discuss the risks and benefits of these with her physician. V. Complete Worksheet 7-2: Alcohol and Breastfeeding (LO 7.4) Total Time: 30 minutes

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 7: Nutrition During Lactation: Conditions and Interventions

Answer Key: 1. 175 pounds ÷ 2.2 pounds per kilogram = 79.5 kg 79.5 kg × 0.5 grams of alcohol per kilogram = 39.75 grams of alcohol 2. 12 ounces of beer = 14 grams alcohol 39.75 grams of alcohol ÷ 14 grams of alcohol per 12-ounce beer = 2.8 beers (12 ounces each) 3. 6:05–6:30 per Table 7.7 4. 1 ounce of dry table wine = 3.1 grams of alcohol 39.75 grams of alcohol ÷ 3.1 grams of alcohol per 1 ounce of wine = 12.8 ounces of wine = 2.56 servings 5. 6:05–6:30 per Table 7.7 6. 1.5 ounces of vodka = 13.9 grams of alcohol = 1 serving 39.75 grams of alcohol ÷ 13.9 grams of alcohol per 1.5 ounces of vodka = 2.85 servings 7. 6:05–6:30 per Table 7.7 [return to top]

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 7: Nutrition During Lactation: Conditions and Interventions

Worksheet 7-1: Case Study—The Use of Medical Herbs, Nutrition Supplements, and Medications During Breastfeeding (LO 7.3) Christine, 32 years old, had type 2 diabetes prior to pregnancy. She is in her 32nd week of pregnancy with her first baby and looks forward to breastfeeding. During her pregnancy, her blood glucose has been managed with insulin instead of the oral hyperglycemic medications she was on prior to conception, and she has been on methyldopa for high blood pressure. She would like to know if she can resume her pre-pregnancy medications and supplements when she begins breastfeeding, as she would prefer to discontinue using insulin if possible. Her pre-pregnancy daily medications and supplements included metformin (for diabetes), lisinopril (an ACE inhibitor for high blood pressure), cinnamon (for diabetes), and fish oils (for healthy lipids). She would also take Echinacea occasionally if she developed a cold and drink herbal teas at bedtime.

Questions: 1. Where can you look for information on the medications and dietary supplements Christine was taking prior to pregnancy?

2. Are there any resources that you would refer her to?

3. Are there any medications, dietary supplements, or medicinal herbs that she was taking prior to pregnancy that should be avoided during lactation?

4. Are there any medications, dietary supplements, or medicinal herbs that she was taking prior to pregnancy that would be considered safe during lactation?

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 7: Nutrition During Lactation: Conditions and Interventions

Worksheet 7-2: Alcohol and Breastfeeding (LO 7.4) Directions: Use Table 7.7 to complete this worksheet. Reminder: 1 kilogram = 2.2 pounds

1. In accordance with the Institute of Medicine Subcommittee on Nutrition During Lactation’s recommendation that “no more than 0.5 grams of alcohol per kilogram of maternal body weight per day” should be consumed, how much alcohol would this equal for a 175-pound woman?

2. Using an internet search, determine how many servings of beer (12 ounces each) this would be.

3. How long should the woman wait to breastfeed if she consumes the amount of beer that is equal to her upper recommended limit (answer to #2)?

4. Using an internet search, determine how many servings of wine (5 ounces each) this would be.

5. How long should the woman wait to breastfeed if she consumes the amount of wine that is equal to her upper recommended limit (answer to #4)?

6. Using an internet search, determine how many servings of vodka (1.5 ounces each) this would be.

7. How long should the woman wait to breastfeed if she consumes the amount of vodka that is equal to her upper recommended limit (answer to #5)?

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 7: Nutrition During Lactation: Conditions and Interventions

ADDITIONAL RESOURCES INTERNET RESOURCES •

Drugs, medicines, and other contaminants in human breastmilk o American Academy of Pediatrics (AAP) Gateway: http://pediatrics.aappublications.org/content/108/3/776.full.pdf+html o REPRPTOX, the Reproductive Toxicology Center’s information system: https://reprotox.org/ o Environmental Working Group: http://www.ewg.org/research/mothersmilk/breast-milk-still-best

•

Lactation and breastfeeding support o Human Milk 4 Human Babies Informed Milksharing Network: http://hm4hb.net/ o Human Milk Banking Association of North America, Inc: http://www.hmbana.org o Bright Future Lactation Resource Center: https://bflrc.org o The Academy of Breastfeeding Medicine: http://bfmed.org/ o Lactation Education Resources: http://www.lactationtraining.com/ o National Center for Education in Maternal and Child Health: http://www.ncemch.org o United States Breastfeeding Committee: http://www.usbreastfeeding.org o International Lactation Consultant Association: http://www.ilca.org/ o La Leche League: http://www.llli.org

•

Science of nutrition o National Library of Medicine (PubMed): http://www.ncbi.nlm.nih.gov/pubmed

•

Public food and nutrition programs o UNICEF Baby-Friendly Hospital Initiative: http://www.unicef.org/documents/baby-friendly-hospital-initiative

•

Nationwide priorities and nutritional health o Breastfeeding Policy: http://pediatrics.aappublications.org/content/115/2/496.abstract o United States ▪ DHHS, HRSA Maternal and Child Health Bureau: http://www.mchb.hrsa.gov

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 7: Nutrition During Lactation: Conditions and Interventions

Department of Agriculture, Women, Infants, and Children (WIC) Program: http://www.fns.usda.gov/wic Canada ▪ Public Health Agency of Canada (A Practical Workbook to Protect, Promote and Support Breastfeeding in Community Based Projects): http://www.phac-aspc.gc.ca/hp-ps/dcadea/publications/ppsb-ppsam-eng.php ▪

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 8: Infant Nutrition

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 8: INFANT NUTRITION

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 3 Chapter Outline ................................................................................................................... 3 Discussion Questions.......................................................................................................... 6 Additional Activities and Assignments .............................................................................. 8 Additional Resources .........................................................................................................12 Internet Resources.................................................................................................................. 12

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to discuss healthy full-term infants born at or after 37 weeks of gestation. The chapter discusses how nutrition is an important component in the complex development of infants. Biological and environmental factors also play key roles in infant growth and development. The Healthy People 2030 objectives related to infants focus on reducing infant deaths and preterm births, along with increasing the proportion of infants who are exclusively breastfed through age 6 months.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 8.1

List factors that are associated with increased risk for health and developmental problems in infants.

8.2

Describe guidelines and tools that can be used to determine appropriate energy and nutrient needs of infants.

8.3

Describe how to assess adequate growth in infants.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 8: Infant Nutrition

8.4

Discuss how feeding and food choices that parents make for their infants can affect later health status.

8.5

Identify infant developmental milestones related to feeding.

8.6

Describe how families and caregivers can access nutrition guidance for infants.

8.7

Identify how nutrition problems may affect infant health and development.

8.8

Cite examples of nutritional interventions that can reduce risk for nutrition and health problems in infancy.

KEY TERMS Full-term infants: Infants born at or after 37 weeks of gestation. Preterm infants: Infants born before 37 weeks of gestation. Infant mortality: Death that occurs within the first year of life. EPSDT: The Early and Periodic Screening, Diagnostic, and Treatment benefit is a part of the Medicaid program and provides coverage for routine well-child visits and dental visits for enrolled children. Intrauterine growth restriction (IUGR): Fetal undergrowth from any cause, resulting in a disproportionately low weight, length, or head circumference percentile for gestational age. Rooting reflex: An involuntary action that occurs when the infant’s mouth or cheek is stroked resulting in the infant’s head turning toward the stimulus and opening his or her mouth. Suckle: A reflexive movement of the tongue moving forward and backward; earliest feeding skill. Reflex: An automatic (unlearned) response that is triggered by a specific stimulus. Gastroesophageal reflux (GER): Movement of the stomach contents upward into the esophagus and may cause spitting up or regurgitation. The condition may require treatment depending on its duration and degree. Most children outgrow GER by 12 to 14 months of age. Hypoallergenic: Foods or products that have a low risk of promoting food or other allergies. Weaning: Gradual process of switching an infant’s diet from breast milk and formula to other foods and fluids.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 8: Infant Nutrition

Colic: A condition marked by a sudden onset of irritability, fussiness, or crying in a young infant between 2 weeks and 3 months of age who is otherwise growing and healthy. Hydrolyzed protein formula: Formula that contains enzymatically digested protein, or single amino acids, rather than protein as it naturally occurs in food. Lactose: A form of sugar or carbohydrate composed of galactose and glucose.

WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • • • • • •

Updated nutrition-related baseline and target measures for infants in the U.S. Healthy People 2030 objectives Updated U.S. vital statistics data related to infant birth and infant mortality New information and table on responsive feeding New section on Dietary Guidelines for Americans 2020–2025 with inclusion for the first time of recommendations for infants Updated information on infant formula types and indications for use New section on baby-led weaning New information and table on healthy beverage consumption in early childhood from the Healthy Eating Research Expert Panel

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CHAPTER OUTLINE I.

Introduction a. Chapter 8 deals with the contributions nutrition makes to the rapid growth and development of healthy full-term and preterm infants. b. Several of the terms offer opportunities to review concepts first introduced in Chapter 4.

II. Assessing Newborn Health List factors that are associated with increased risk for health and developmental problems in infants. (LO 8.1) a. This chapter defines a full-term infant as one born at 37–42 weeks gestation, and usually weighing 2500–3800 grams (5.5–8.5 pounds). b. Most (89%) of infants born in the United States are born full-term. c. Premature or preterm infants are defined as those born before 37 weeks gestation, and they are categorized by their birth weight as having low

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 8: Infant Nutrition

d. e. f. g. h. i. j. k. l.

birthweight (less than 2500 grams), very low-birthweight (less than 1500 grams), or extremely low-birthweight (less than 1000 grams). Birthweights and infant mortality rates are internationally recognized as markers for newborn health. In 2019, the U.S. infant mortality rate was 5.6 deaths per 1000 live births. Table 8.1 depicts some of the Healthy People 2030 objectives that are related to infants. Ways to combat infant mortality are presented. The theory that critical periods determine the course of development has implications for feeding and nutrition. For an infant, “the mouth is a source of oral pleasure and exploring, an important form of early learning.” Gross motor skills are shown in Figure 8.1, and major infant reflexes are listed in Table 8.3. Digestive system development underlies successful feeding, and the gut is functional at birth. Parenting skills, including recognition and responses to feeding cues, are learned throughout all of the stages of infant development.

III. Energy and Nutrient Needs Describe guidelines and tools that can be used to determine appropriate energy and nutrient needs of infants. (LO 8.2) a. A human’s greatest caloric need occurs during infancy, the most rapid period of growth. b. Caloric intakes vary widely from 80 to 120 calories per kilogram during the first 6 months (average 108) and decrease to an average of 98 calories/kg during the second 6 months of life, depending on factors such as metabolic rate and growth rate. c. Among the nutrients of specific concern are protein and fats, especially essential fatty acids, as well as fluoride, vitamin D, sodium, and iron. d. Lead is addressed in this section because of related metabolic and potential toxic effects. IV. Growth Assessment Describe how to assess adequate growth in infants. (LO 8.3) a. CDC and WHO growth charts (see http://www.cdc.gov/growthcharts/) reflect diverse growth patterns. These allow healthcare providers to monitor infant status and detect potential problems early in life. b. Head circumference measures are used to monitor brain growth. Patterns of change over time are more indicative of development than single height and weight measurements. c. Accurate measurements are the basis of meaningful monitoring, and Table 8.9 gives clues to measuring accurately. V. Feeding in Early Infancy

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 8: Infant Nutrition

Discuss how feeding and food choices that parents make for their infants can affect later health status. (LO 8.4) a. Detailed breastfeeding information is presented in Chapter 6, and the key message that breastfed infants need no other fluids until 4–6 months of age is reiterated here. b. For formula-fed infants, Table 8.11 compares different types of infant formulas, provides indications for use, and gives examples of products for each type of formula. c. Cow’s milk is not recommended before age 1. (The instructor may want to cover this section as part of Chapters 6 and 7.) d. Discussion of the prevalence and increased variety of formulas gives the instructor an opportunity to emphasize the broad range of needs in infant feeding. VI. Development of Infant Feeding Skills Identify infant developmental milestones related to feeding. (LO 8.5) a. Newer developmental models emphasize that it is not age alone but also developmental stages that determine feeding skills (Table 8.12). b. Infant reflexes, summarized in Table 8.3, are used in the first few weeks to signal wants and needs; after this period, other cues take over. c. Parents develop skills to recognize and respond to infant cues, and information such as that in Table 8.4, as well as plotting height and weight change on growth grids, can help to reassure parents that the infant is getting enough to eat. d. Learning enough about an infant’s development to choose appropriate foods for infants has more to do with safety aspects than counting the number of food group servings. e. Topics covered include the introduction of complementary foods, the importance of infant feeding position, food texture and development, first foods, and foods to avoid. f. Additionally, the process of transitioning to a cup from a bottle or breast is explained. g. Weaning to a cup may be accompanied by constipation due to decreased fluid intake. h. Water and juice as potential fluid alternatives to milk have drawbacks when given to infants. i. Determining how much food is enough for infants and how infants learn food preferences are discussed. VII. Nutrition Guidance Describe how families and caregivers can access nutrition guidance for infants. (LO 8.6) a. Sources for parents on nutrition advice, including the WIC program, Bright Futures Nutrition, and Zero to Three, are discussed.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 8: Infant Nutrition

b. Table 8.12 provides key topics regarding infant feeding, as well as sample content from various nutrition education materials related to each key topic. c. The section on supplements mentions several specific nutrients that may be problematic in infant diets, including fluoride, iron, and vitamin B12. d. Cross-cultural considerations: Formulas and commercially available baby foods reflect the dominant American culture rather than ethnic diversity. e. Infant feeding and child rearing practices reflect culture and family traditions. f. To promote healthy infant feeding practices, health care personnel can encourage and support parenting competence and support the dignity of the family unit. VIII.

Common Nutritional Issues and Concerns Identify how nutrition problems may affect infant health and development. (LO 8.7)

a. Colic is a condition characterized by irritability, fussiness, and crying in a young infant who is otherwise healthy and well-fed. b. The causes and treatments of colic are discussed. c. Other common problems are iron-deficiency anemia, constipation and diarrhea, early childhood dental caries (also called baby bottle caries), and food allergies and intolerance, specifically lactose intolerance. d. Vegetarian diets are also covered in this section. e. Controlling the volume of the infant’s diet and providing adequate supplementation can ensure a health-promoting infant diet in a vegetarian household. IX. Nutrition Intervention for Risk Reduction Cite examples of nutritional interventions that can reduce risk for nutrition and health problems in infancy. (LO 8.8) a. Early Head Start is an example of a health promotion program for infants; services are likely to be coordinated with other community services. b. Screening stems from a policy approach to health; the most common metabolic disorders for which newborns are screened include PKU, congenital hypothyroidism, galactosemia, and sickle cell disease.

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DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 8: Infant Nutrition

1. Name five measures for assessing newborn health. What health characteristic does each measure, and how is that related to nutrition? (LO 8.1) 2. How do feeding reflexes change in the first 4–6 weeks? What happens then? For infants, the mouth is a source of pleasure and learning. Is this still true for adults? Discuss the role of enjoyment or pleasure in food and drink consumption. (LO 8.5) 3. The relative percentage of calories per kilogram body weight declines as the infant grows. What are the calorie needs (on average) of a 0 to 6-month-old infant compared to a 6- to 12-month-old? What do you think this figure is in adulthood? [Roughly 30–35 kcal/kg body weight] (LO 8.2) 4. Besides a higher number of calories per kilogram body weight, how else are nutrient needs different in infancy than adulthood? [Infants need higher proportions of calories from fat and cholesterol, and a higher proportion of protein per unit body weight.] (LO 8.2) 5. Why are growth curves useful for monitoring infant health? [Rates, patterns of change, “blips” highlight potential problems or measurement error; Table 8.9 shows how to reduce errors in measuring.] Where else in health monitoring have you seen growth-type curves? [Weight gain grids during pregnancy] (LO 8.3) 6. If you were a parent following a vegetarian diet, what would be some of the questions you would have regarding nourishment of an infant? Compare how issues might be similar or different in a vegan and a lacto-ovo vegetarian household. (LO 8.7) 7. Adults have a tendency to share food with their children. Which foods are safe to share with infants, and which are unsafe? Can you describe any cultural variation regarding adults sharing food and drink with their young children? (LO 8.6) 8. Breast milk is the preferred food for infants, but supplementation with fluoride is suggested to enhance tooth development in instances where water does not contain fluoride. What are some circumstances where an infant might ingest water that is not fluoridated? Should all bottled water be fluoridated? (LO 8.6) 9. “Food preferences developed in infancy set the stage for lifelong food habits.” The author suggests that the feeding relationship can help to develop trust and security in an infant. What do you think about this topic? How might parental attitudes toward food influence very young children? (LO 8.5) 10. What are benefits of homemade baby food? What are some cautions for caregivers who want to make baby food at home? What would you advise someone about the addition of salt, pepper, sugar, or other seasonings to baby foods? (LO 8.5)

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 8: Infant Nutrition

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ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. Answers Found on the Internet (LO 8.2) Total Time: 30 minutes Go to http://www.webmd.com. Pretend that you are a new mother and want to find out how best to feed your infant. Write down at least three questions that you might have about feeding your infant and find the best answers at that site. How does the information at the website compare to information in the text? 2. Infants with Colic (LO 8.7) Total Time: 30 minutes Divide the class into groups of 2. Give them this scenario: A single-parent, working mom brings a 7-month-old baby with “colic” to the clinic. She is highly distressed because her home daycare provider has threatened to quit providing care unless the mom changes from breastfeeding to formula. Assign one student in each group to provide information that supports the recommendation of continued breastfeeding and have the other student provide information that supports the recommendation of having the mom initiate formula. Be sure to have each student identify important information needed to assess the infant’s dietary needs and family circumstances affecting diet. 3. Swimming Guidelines for Infants and Toddlers (LO 8.2) Total Time: 40 minutes The American Academy of Pediatrics issued a statement regarding swimming programs for infants and toddlers. [A written copy is in Pediatrics. 2000;105(4): 868-870, available at: http://pediatrics.aappublications.org/content/105/4/868] Over 5 to 10 million infants and preschool children participate in formal aquatic instruction programs. There is great concern over programs that attempt to develop water survival skills in infant/toddler aquatic programs. Some programs, however, focus on aquatic adjustment and parents having fun in the water with their infant. How would participation in water activities impact calorie and protein needs of infants? Would this affect interpretation of growth chart plots? Discuss the pros and cons of participation. Take a poll of students’ views on whether they feel this will promote physical exercise in school-age and preadolescent children. 4. Complete Worksheet 8-1: Case Study—How Is Stan’s Growth? (LO 8.1) Total Time: 20–30 minutes Answer Key: 1. Age Birth 2 months

Weight-for-Age % 3rd 3rd

Length-for-Age % 3rd 3rd

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 8: Infant Nutrition

3 months 4 months 5 months 6 months

10th 10th 10th 10th

2. Possible measurement error. Review Table 8.9. Also, “There is a wide range of appropriate growth patterns in infancy. Healthy infants may have brief periods when their weight gain is slower or more rapid than at other times. Slight variations in growth rate may result from illness, inappropriate feeding routine, or family disruption” (p. 228). 3. Page 228: “Frequent measurements of weight, length, and head circumference during infancy will facilitate early identification of potential problems such as slow or excessive weight gain or slow linear growth.” Furthermore, “Accurate growth measurements and interpretation of growth rates are important components in evaluating an infant’s nutritional status.” 4. In a group of 100 children lined up in a row, 10 would be smaller than Stan and 90 would be bigger. His growth falls near the low end of normal. 5. Complete Worksheet 8-2: Infant Formulas vs. Human Breastmilk (LO 8.4) Total Time: 20–30 minutes Answer Key: 1. Breastfeeding provides protection against infections as well as numerous chronic conditions and may help prevent the development of allergies. 2. Infant formula is the best alternative to human breast milk, as it provides the nutrients infants need to grow. Bonding between the mother and child is still possible when feeding an infant from a bottle. 3. Answers could include sudden infant death syndrome (SIDS), allergies, asthma, obesity, diabetes, ear and respiratory infections, diarrhea, and meningitis. 4. Human breastmilk is sometimes called nature’s perfect food for an infant because it contains lactose, protein, and fat in forms that are readily digestible by an infant’s digestive system. 5. Some infant formulas contain vitamins and nutrients that are not found in breastmilk. Other advantages include convenience, as either parent can feed the newborn; flexibility, because there is no need to pump or schedule around the breastfeeding schedule, there is less need for privacy, and people other than just the mother can feed the newborn; feeding time and frequency, since feeding an infant formula instead of breastmilk may take less time and require fewer feedings; and the mother’s diet not influencing the baby’s nutrition.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 8: Infant Nutrition

Worksheet 8-1: Case Study—How Is Stan’s Growth? (LO 8.1) Stan, 6 months old, has been seen by a WIC registered dietitian for concerns about slow growth every month for the past 4 months. His length and weight data are as follows: Age Birth 2 months 3 months 4 months 5 months 6 months

Weight 5 pounds 8 ounces 8 pounds 12 ounces 11 pounds 1 ounce 12 pounds 8 ounces 13 pounds 10 ounces 15 pounds 2 ounces

Length 18 inches 21 inches 23 ½ inches 23 ½ inches 24 ½ inches 25 ¼ inches

Stan has been bottle-fed since the second week of life because his mother was concerned she wasn’t producing adequate amounts of breast milk to support his growth. Questions: 1. Complete the following table using the World Health Organization (WHO) growth chart (http://www.cdc.gov/growthcharts/who_charts.htm). Age

Weight-for-Age %

Length-for-Age %

Birth 2 months 3 months 4 months 5 months 6 months 2. What is a possible explanation for the “jump” in Stan’s length at 3 months of age?

3. Why is it important to take frequent growth measurements when tracking an infant’s growth?

4. What does Stan’s current weight-for-age percentile say about his weight?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 8: Infant Nutrition

Worksheet 8-2: Infant Formulas vs. Human Breastmilk (LO 8.4) Directions: Use http://kidshealth.org/en/parents/breast-bottle-feeding.html#kha_41 to answer the following questions.

1. Why do health organizations, such as the American Academy of Pediatrics, the American Medical Association, and the World Health Organization, endorse breastfeeding infants instead of using infant formula?

2. What advice should be given to women who choose not to breastfeed or are not able to breastfeed?

3. List at least three infections or conditions that breastfeeding may help prevent.

4. Why is human breast milk sometimes referred to as nature’s perfect food for an infant?

5. What are some of the potential advantages of formula feeding instead of breastfeeding?

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 8: Infant Nutrition

ADDITIONAL RESOURCES INTERNET RESOURCES •

Pediatric nutrition and medical information o

American Academy of Pediatrics: http://www.aap.org

Academy of Nutrition and Dietetics: http://www.eatright.org

Pediatrics journal: http://www.pediatrics.org

Health Canada—Nutrition for Healthy Term Infants: http://www.hcsc.gc.ca/fn-an/nutrition/infant-nourisson/recom/index-eng.php

•

General nutrition o

•

Food Allergy Research & Education: http://www.foodallergy.org

Science of nutrition o

National Library of Medicine (PubMed): http://www.ncbi.nlm.nih.gov/pubmed

•

Public food and nutrition programs o

U.S. Department of Agriculture, Special Supplemental Nutrition Program for Women, Infants and Children (WIC): http://www.fns.usda.gov/wic

•

Nationwide priorities and nutritional health o

United States—Centers for Disease Control and Prevention, National Center for Health Statistics: http://www.cdc.gov/nchs

Canada—Canadian Perinatal Surveillance System: http://www.phacaspc.gc.ca/rhs-ssg/bwga-pnag/

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 9: Infant nutrition: Conditions and interventions

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 9: INFANT NUTRITION : CONDITIONS AND INTERVENTIONS

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 3 Chapter Outline ................................................................................................................... 4 Discussion Questions.......................................................................................................... 6 Additional Activities and Assignments .............................................................................. 7 Additional Resources ......................................................................................................... 11 Internet Resources.................................................................................................................. 11

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to discuss the common nutritional concerns of preterm infants, infants with special health care needs, and infants with developmental delays. These infants are at increased risk of compromised nutrition status and altered growth. Indicators of nutritional risk include increased or decreased energy needs, altered growth, drug–nutrient interactions, impaired nutrient utilization, poor feeding skills, metabolic disorders, and the use of partial or exclusive enteral or parenteral nutrition.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 9.1

Describe factors that put infants at nutritional risk and how nutritional assessment and interventions address these risks.

9.2

Compare the energy and nutrition needs of preterm infants, infants with special health care needs, and healthy full-term infants.

9.3

Describe how the growth of preterm infants and infants with special health needs is tracked and interpreted.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 9: Infant nutrition: Conditions and interventions

9.4

Identify nutrition problems that are more frequently identified in preterm infants and infants with special health care needs.

9.5

Provide examples of nutrition assessment and interventions for infants with special health care needs and chronic illness.

9.6

Identify appropriate nutrition intervention strategies for infants with slow linear growth or weight gain.

9.7

Describe how families of high-risk infants and infants with special health care needs access nutrition resources and services in their communities.

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KEY TERMS Developmental delay: Slow to meet or not reaching milestones expected for a child’s age in one or more areas of development: communication, motor, cognition, socialemotional, or adaptive skills. Extremely low-birthweight infant (ELBW): An infant weighing less than 1000 grams at birth. Very low-birthweight infant (VLBW): An infant weighing less than 1500 grams at birth. Low-birthweight infant (LBW): An infant weighing less than 2500 grams at birth. Down syndrome or trisomy 21: This is a condition in which three copies of chromosome 21 occur. It may be associated with low muscle tone (hypotonia), short stature, feeding difficulty and risk of overweight. Seizures: Condition in which electrical nerve transmission in the brain is disrupted, resulting in periods of loss of function that vary in severity. Catch-up growth: The accelerated growth that occurs following a period of restricted or slow growth. Developmental disabilities: A group of conditions due to an impairment in physical, learning, language, or behavioral areas. These conditions have onset in the developmental period, may impact daily functioning, and usually last throughout a person’s lifetime. Postmenstrual age: The gestational age plus the chronological age, usually reported in weeks. This is the preferred term during the neonate’s time in the hospital. For

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 9: Infant nutrition: Conditions and interventions

example, an infant born at 30 weeks who is now 4 weeks old has a postmenstrual age of 34 weeks. Enteral feeding: Method of delivering nutrients directly to the digestive system, in contrast to methods that bypass the digestive system. Parenteral feeding: Delivery of nutrients directly into the bloodstream. Parenteral nutrition support: Intravenous nutrition or orally modified formulas needed because of inability to consume a regular diet. Gavage feeding: A procedure where a tube is passed through the nose or mouth into the stomach. This is used to feed preterm or newborn infants who are not yet able or have weak or uncoordinated ability to suck and swallow. Gastrostomy feeding: Form of nutrition support for delivering nutrition via a tube placed directly into the stomach. A surgical procedure creates an opening through the abdominal wall and stomach. Jejunostomy feeding: Another form of nutrition support that delivers nutrition via tube directly into the small intestine. Non-nutritive sucking: The sucking by newborns and young infants on items that do not provide fluid or nutrition. Necrotizing enterocolitis (NEC): Condition with inflammation or damage to a section of the intestine, with a grading from mild to severe. Orogastric (OG) feeding: A form of enteral nutrition support for delivering nutrition via tube placed from the mouth to the stomach. Congenital anomalies: Conditions evident in newborns that are diagnosed at or near birth, usually as a genetic or chronic condition, such as spina bifida or cleft lip or palate. Early Intervention Program: Educational intervention for the development of children from birth up to 3 years of age. Cleft lip and palate: Condition in which the upper lip and/or palate are not completely formed and in need of surgical correction. The cleft may contribute to feeding problems in early infancy. [return to top]

WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: •

Updated DRI for energy for infants

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 9: Infant nutrition: Conditions and interventions

• •

Updated information on nutrient composition of infant formulas Expanded section on growth in preterm infants: how to determine corrected age, how to plot measurements on the World Health Organization (WHO) growth charts, and how to assess growth

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CHAPTER OUTLINE I.

Introduction a. “Most infants are born healthy.” b. Infants at risk for inadequate nutritional status, such as those born prematurely or those with special health care needs or developmental delay, are considered “children and youth with special health care needs (CYSHCN).” c. Chapter 9 has a clinical/medical nutrition focus and uses many terms specific to medical conditions. d. Learning metric to English conversions for height and weight measurements as well as the many clinical margin definitions will be useful for describing and understanding conditions that can affect the growth and development of children.

II. Infants at Risk Describe factors that put infants at nutritional risk and how nutritional assessment and interventions address these risks. (LO 9.1) a. More preterm infants are surviving to childhood than ever before. b. They often have chronic conditions that affect feeding and nutritional status. c. Three main risk categories are: (1) infants born before 34 weeks of gestation; (2) infants born with consequences of abnormal development during pregnancy such as Down syndrome, a genetic syndrome; and (3) infants at risk for chronic health problems such as a challenging home environment. d. Just as for healthy infants, questions about growth, dietary adequacy, and feeding patterns are used to assess nutritional status. However, the standards for preterm infant comparison are different. III. Energy and Nutrient Needs of Preterm Infants and Infants with Special Health Care Needs and/or Developmental Delay Compare the energy and nutrition needs of preterm infants, infants with special health care needs, and healthy full-term infants. (LO 9.2) a. The needs of each infant are unique. b. Needs are met through individualized, closely monitored, and frequently modified approaches. c. The AAP recommends energy requirements of 105–130 cal/kg for preterm infants.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 9: Infant nutrition: Conditions and interventions

d. The DRI for protein in the first 6 months of an infant’s life is 1.52 g/kg of body weight. e. However, preterm infants and infants with special health care needs may require more or less than the standard DRI. f. Fat intake is generally not restricted in infants, particularly those who are preterm. g. Medium-chain triglycerides provide nutrition when the infant is unable to metabolize fats found in human milk. h. Use of vitamins, minerals, and human milk fortifiers is customized according to infant need. IV. Growth of Infants at Risk or with Special Health Care Needs Describe how the growth of preterm infants and infants with special health needs is tracked and interpreted. (LO 9.3) a. The goal for a newborn’s first year is to maintain growth appropriate for age and gender. b. Slow growth may signal underlying conditions; monitoring helps to pinpoint problems. c. An important concept for infant nutrition is gestational age. d. Correcting for the gestational age of infants with special health care needs is described on p. 247. For an example of how such a correction is used, see Figure 9.1. e. “Intrauterine growth may not predict postnatal growth for some infants whose birth removes them from adverse exposure within the intrauterine environment. f. In such cases, the rate of growth after birth may improve after delivery and in the first year.” V. Nutrition for Infants with Special Health Care Needs Identify nutrition problems that are more frequently identified in preterm infants and infants with special health care needs. (LO 9.4) a. Table 9.1 categorizes the nutritional concerns of infants with special health care needs (i.e., growth, nutritional adequacy, and feeding). b. An example of a condition with developmental delay affecting nutrition is Down syndrome. VI. Severe Preterm Birth and Nutrition Provide examples of nutrition assessment and interventions for infants with special health care needs and chronic illness. (LO 9.5) a. VLBW (very low-birthweight—below 1500 grams) and ELBW (<1000 g) infants require intensive care at minimum and potentially nutrition support via parenteral or enteral feedings.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 9: Infant nutrition: Conditions and interventions

b. The nutritional focus centers on providing adequate calories for growth and food safety. c. Comparisons of the nutritional composition of preterm and term formulas (Table 9.2) and possible feeding complications (Table 9.3) highlight some of the special needs of sick infants. VII. Infants with Congenital Anomalies and Chronic Illness Identify appropriate nutrition intervention strategies for infants with slow linear growth or weight gain. (LO 9.6) a. Individualizing treatment and tracking progress are especially important for high-risk infants, such as those with congenital anomalies (e.g., cleft lip and palate) or genetic disorders (e.g., phenylketonuria). b. Since folic acid fortification in grain products began, rates of spina bifida and related conditions have declined significantly. VIII.

Nutrition Interventions

a. Nutrition interventions are geared to specific problems. Nine approaches to potential interventions are bulleted on p. 256. IX. Nutrition Services Describe how families of high-risk infants and infants with special health care needs access nutrition resources and services in their communities. (LO 9.7) a. Federal programs provide wide access to services that can help early on in a child’s life. [return to top]

DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class. 1. What does it mean to be an infant at risk? Name some conditions that result in classification as an at-risk infant. What do these conditions imply for nutritional health? (LO 9.1) 2. In your opinion, is standard growth a more acceptable term than normal growth or typical growth? What do these terms mean to you? Generate a few examples of “family-friendly” phrases to describe infants with conditions that place them at nutritional risk (such as VLBW or Down syndrome). (LO 9.3) 3. Parents of a child with special needs may grieve for the loss of their hoped-for perfect or healthy child. Think of an occasion where you or someone you know

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 9: Infant nutrition: Conditions and interventions

grieved for a loss. How did grief affect your (or the other person’s) eating habits? (LO 9.1) 4. Describe examples of required adjustments made in the assessment of and intervention for an infant with a special condition. [Specialized growth charts for Down syndrome, greater caloric and protein density in diets for LBW (under 2500 grams) infants; a list is included in Chapter 11.] Why is it (or not) in the public health interest to develop unique tools for special needs infants? (LO 9.3) 5. The WIC program includes birthweight in its infant risk assessment. What makes birthweight a useful contributor to a risk profile? (LO 9.1) 6. Discuss factors contributing to intrauterine growth and how these affect subsequent growth of an infant. What is typical catch-up growth for infants? What are factors that can slow growth? (LO 9.3) [return to top]

ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. Down Syndrome and Growth Charts (LO 9.3) Total Time: 20 minutes Search the web for growth charts for an infant with Down syndrome. Are they gender-specific? What sets them apart from the CDC growth charts? List three benefits of disease-specific growth charts and two reasons why all infants should use the same growth charts. 2. Homework and Role Playing (LO 9.5) Total Time: 30 minutes Pretend that you are a dietitian who specializes in infant and childhood nutrition. Parents of a preterm infant are referred to you for guidance on which formula to use for their newborn because breastfeeding is not an option. Develop 3–5 talking points for educating the parents about formula used for premature infants (see Table 9.2). Based on the nutrient composition, how does this type of formula compare to formula used for full-term infants? What is one question you might anticipate from the parents about formula specific for premature babies? Go online and find an online address for a manufacturer of formula specific for preterm newborns (e.g., Mead Johnson Nutrition, Abbott Nutrition, Novartis, Nestle). Do their marketing points match the educational talking points you developed? Answer the question that you thought would be asked by the parents. In class: Team up to role-play dietitian and parents. (If time permits, have team members trade places.) Debrief the class to summarize talking points for preterm formula and clarify areas that were inaccurate or confusing. 3. Homework—MCT Oil: (LO 9.2) Total Time: 30 minutes The goal of the activity is to further students’ understanding of the

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 9: Infant nutrition: Conditions and interventions

implications of “adding special products.” Locate the article Hay WW, Jr. (2008) Strategies for feeding the preterm infant. Neonatology 94(4): 245-254 (available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912291/). Have the class comment on the recommendations for adding products to foods. What would be the challenges as the infant becomes a toddler and still needs extra calories? Note that the estimated cost of MCT oil is $20/quart. Calculate the cost of trying to add 1 ½ tsp MCT oil with food at meals three times per day. [1 qt = 4 cups = 192 tsp; $20 ÷ 192 tsp = $0.104/tsp × 1.5 tsp × 3/day = $0.47/day.] 4. Complete Worksheet 9-1: Case Study—Tube Feeding Plus Oral Food Intake (LO 9.5) Total Time: 30–40 minutes Answer Key: 1. Page 252: “Infant feeding guidelines for term infants are appropriate for use in most preterm infants using their corrected age. Term infants can be introduced to complementary foods at 6 months of age. An infant born at 32 weeks gestation would be ready for complementary foods at 8 months of age, which is a corrected age of 6 months.” 2. Based on a correction for gestational age, Emma is at the 6-month measurements on the growth charts. Her weight is approximately at the 45th percentile, and her length is approximately at the 55th percentile. 3. See Table 9.3. 4. Early Intervention Programs funded by the Individuals with Disabilities Education Act (IDEA) Part C, Early Head Start, WIC, State Children with Special Health Care Needs. 5. Complete Worksheet 9-2: Nutrition Needs of Preterm Infants (LO 9.2) Total Time: 30–40 minutes Answer Key: 1. 105 to 130 cal/kg 2. “Infants who are born before 34 weeks of gestation have higher energy needs than late preterm and term infants.” 3. In the first 6 months of an infant’s life, the daily recommended intake of protein is 1.52 g/kg of body weight. This amount declines in the second 6 months of an infant’s life to 1.2 g/kg. The requirements of infants with special health care needs may be the same, less than, or more than those of other infants. 4. A micropreterm infant is one who is born before 30 weeks gestation. Micropreterm infants may need as much as 4.5 g of protein/kg of body weight/day. 5. Compared to children and adults, infants need a higher percentage of their daily calories from fat.

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 9: Infant nutrition: Conditions and interventions

Worksheet 9-1: Case Study—Tube Feeding Plus Oral Food Intake (LO 9.5) Emma, 8 months old, was born at 32 weeks gestation with fetal alcohol spectrum disorder and a heart murmur due to maternal alcohol abuse. She has lived with a foster mother, who would like to adopt her, since she was 2 months old. Emma has had multiple complications from her premature birth (e.g., needing to be tube fed via a nasogastric tube for the first 8 weeks of life) that have necessitated the use of tubes in her nose and throat. This has resulted in an aversion to having anything placed in her mouth, including a feeding tube or a spoon. Emma has been fed regular infant formula through a gastrostomy tube since she was 2 months old. Her current weight is 15 pounds 5 ounces, and her length is 26 inches. Emma’s foster mother is looking forward to starting solid foods with Emma this week per her pediatrician’s advice.

Questions: 1. Why would Emma’s physician want to delay the introduction of solid foods until she is 8 months old?

2. How are Emma’s height and length for her age? (Hint: Remember to account for corrected age!)

3. What signs of feeding problems should Emma’s foster mother monitor her for?

4. What are some examples of nutrition services that Emma would be eligible for?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 9: Infant nutrition: Conditions and interventions

Worksheet 9-2: Nutrition Needs of Preterm Infants (LO 9.2) Directions: Use the information in the “Energy and Nutrient Needs of Preterm Infants and Infants with Special Health Care Needs and/or Developmental Delay” section of Chapter 9 to complete this worksheet.

1. According to the American Academy of Pediatrics, what is the daily estimated energy requirement (EER) for an infant born before 34 weeks of gestation?

2. How does the daily EER of an infant born before 34 weeks of gestation compare to the daily EER of late preterm (born between 34 and 37 weeks of gestation) and term infants (born at or after 37 weeks gestation)?

3. What is the DRI of protein for an infant during their first year of life? How do the protein needs of a preterm infant compare to the protein needs of a term infant?

4. What is a micropreterm infant? What are the daily protein needs of a micropreterm infant?

5. How do an infant’s daily fat requirements compare to those of older children and adults?

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 9: Infant nutrition: Conditions and interventions

ADDITIONAL RESOURCES INTERNET RESOURCES •

Science of nutrition o

National Library of Medicine: http://ncbi.nlm.nih.gov/pubmed

National Academies of Sciences Engineering & Medicine Health and Medicine Division: http://www.nationalacademies.org/hmd/health-andmedicine-division

•

Infant nutrition: conditions and interventions o

Emory University, Department of Pediatrics: http://www.emory.edu/departments/pediatrics/index.html

Mead Johnson Nutrition: http://www.meadjohnson.com

Nestle Corporation: http://www.nestlebaby.com/

Abbott Nutrition, Infant & New Mother Nutrition Center: http://abbottnutrition.com/categories/infant-and-new-mother/infantand-new-mother-nutrition-center

United Cerebral Palsy: http://ucp.org/

Neonatology on the Web: http://www.neonatology.org/

Division of Developmental Disabilities of the Centers for Disease Control and Prevention: http://www.cdc.gov/ncbddd/developmentaldisabilities/index.html

•

Public food and nutrition programs o

National Association of Councils on Developmental Disabilities: http://www.nacdd.org/

Early Childhood Technical Assistance Center: http://www.ectacenter.org/

National Organization on Fetal Alcohol Syndrome (NOFAS): http://www.fasdunited.org

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 10: Toddler and preschooler nutrition

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 10: TODDLER AND PRESCHOOLER NUTRITION

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 4 Chapter Outline ................................................................................................................... 4 Discussion Questions.......................................................................................................... 7 Additional Activities and Assignments .............................................................................. 8 Additional Resources ......................................................................................................... 11 Internet Resources.................................................................................................................. 12

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to describe the growth and development of toddlers and preschool-age children and their relationships to nutrition and the establishment of eating patterns. The eating and health habits established at this early stage of life may impact food habits and subsequent health later in life. Important aspects of this stage of development include learning about and accepting new foods, developing feeding skills, and establishing healthy food preferences.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 10.1

List two Healthy People 2030 objectives related to toddlers and preschoolage children.

10.2

Identify the screening tool used for assessing underweight, overweight, or children with obesity.

10.3

Describe two strategies that parents/caretakers can employ to encourage toddlers/preschoolers to accept a variety of foods in their diets.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 10: Toddler and preschooler nutrition

10.4

Explain what influences energy needs of young children.

10.5

Identify one common nutritional problem of young children and describe prevention strategies.

10.6

Define children who are overweight or those with obesity.

10.7

Describe the components of a healthy diet for young children as recommended by health and professional organizations and agencies.

10.8

Identify the basic premise upon which Bright Futures Nutrition is based.

10.9

Identify one public food or nutrition program that provides services to young children and describe the program’s strategies in improving the nutrition of young children.

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KEY TERMS Growth velocity: The rate of growth over time. Toddlers: Children between the ages of 1 and 3 years. Preschool-age children: Children between the ages of 3 and 5 years who are not yet attending kindergarten. Recumbent length: Measurement of length while the child is lying down. Recumbent length is used to measure toddlers less than 24 months of age and those between 24 and 36 months who are unable to stand unassisted. Stature: Standing height. Preloads: Beverages or food such as yogurt in which the energy/macronutrient content has been varied by the use of various carbohydrate and fat sources. The preload is given before a meal or snack and subsequent intake is monitored. This study design has been employed by Birch and Fisher in their studies of appetite, satiety, and food preferences in young children. Dietary Reference Intakes (DRIs): Quantitative estimates of nutrient intakes, used as reference values for assessing the diets of healthy people. DRIs include Recommended Dietary Allowances (RDAs), Adequate Intakes (AI), Tolerable Upper Intake Levels (UL), and Estimated Average Requirements (EAR). Recommended Dietary Allowances (RDAs): The average daily dietary intake levels sufficient to meet the nutrient requirements of nearly all (97–98%) healthy individuals in a population group. RDAs serve as goals for individuals.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 10: Toddler and preschooler nutrition

Anemia: A reduction below normal in the number of red blood cells per cubic mm in the quantity of hemoglobin, or in the volume of packed red cells per 100mL of blood. This reduction occurs when the balance between blood loss and blood production is disturbed. Hemoglobin: A protein that is the oxygen-carrying component of red blood cells. A decrease in hemoglobin concentration in red blood cells is a late indicator of iron deficiency. Hematocrit: An indicator of the proportion of whole blood occupied by red blood cells. A decrease in hematocrit is a late indicator of iron deficiency. Early childhood caries (ECC): The presence of one or more decayed (noncavitated or cavitated lesions), mission (due to caries), or filled tooth surfaces in any primary tooth in a child less than 6 years of age. Fluorosis: Permanent white or brownish staining of the enamel of teeth caused by excessive ingestion of fluoride before teeth have erupted. Food security: Access at all times to sufficient supply of safe, nutritious foods. Hemolytic uremic syndrome (HUS): A serious, sometimes fatal complication associated with illness caused by E. coli 0157:H7, which occurs primarily in children under the age of 10 years. HUS is characterized by renal failure, hemolytic anemia, and a severe decrease in platelet count. Overweight: Body mass index-for-age between the 85th and 94th percentiles. Obesity: Body mass index-for-age greater than or equal to the 95th percentile. BMI rebound: A normal increase in body mass index that occurs after BMI declines and reaches its lowest point at 4–6 years of age. Heart disease: The leading cause of death and a common cause of illness and disability in the United States. Coronary heart disease is the principal form of heart disease and is caused by buildup of cholesterol deposits in the coronary arteries, which feed the heart. LDL cholesterol: Low-density lipoprotein cholesterol, the lipid most associated with atherosclerotic disease. Diets high in saturated fat, trans fatty acids, and dietary cholesterol have been shown to increase LDL cholesterol levels. Familial hyperlipidemia: A condition that is hereditary and results in high levels of serum cholesterol and other lipids. Trans fatty acids: Fatty acids that have unusual shapes resulting from the hydrogenation of polyunsaturated fatty acids. Trans fatty acids also occur naturally in small amounts of foods such as dairy products and beef.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 10: Toddler and preschooler nutrition

Atherosclerosis: A type of hardening of the arteries in which cholesterol is deposited in the arteries. These deposits narrow the coronary arteries and may reduce the flow of blood in the heart. Tolerable Upper Intake Levels: Highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population; gives levels of intake that may result in adverse effects if exceeded on a regular basis. Vegan diet: The most restrictive of vegetarian diets, allowing only plant foods. Macrobiotic diet: This diet falls between semi-vegetarian and vegan diets and includes foods such as brown rice, other grains, vegetables, fish, dried beans, spices, and fruits. [return to top]

WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • • • • • • • • •

Updated Healthy People objectives with 2030 information Revised the estimated energy requirements and table for boys and girls with the updated DRI for energy information and calculations Updated charts with total kilocalorie intake of carbohydrates, protein, and fat New information on new growth charts for boys and girls ages 2–18 years for extended body mass index (BMI) Updated poverty percentages, including ethnic groups at risk Updated changes to the Childrens Food and Beverage Advertising Initiative (December 2022) Expanded section on blood levels Updated information on dental carries Strengthened section on food security to include the impact of COVID-19 Updated information on prevalence of overweight and obese toddlers and preschool-aged children

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CHAPTER OUTLINE I.

Introduction a. Toddlers are 1- to 3-year-old children; preschoolers are 3 to 5 years old. b. The years after infancy are characterized by decreased growth velocity and a corresponding decline in appetite.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 10: Toddler and preschooler nutrition

c. Increases in fine and gross motor skills affect development and include feeding practices and dietary intake. d. Dietary adequacy has long-term implications: undernutrition can impair cognitive development. e. The development of eating and health habits during these ages can influence habits and health in later life. II. Tracking Toddler and Preschooler Health List two Healthy People 2030 objectives related to toddlers and preschool-age children. (LO 10.1) a. The home environment is an important consideration when evaluating the nutritional status of children. b. Issues such as poverty and food insecurity can influence the establishment of healthy eating habits. c. The Healthy People 2030 objectives (Table 10.1) are useful for setting population health goals. III. Normal Growth and Development Identify the screening tool used for assessing underweight, overweight, or children with obesity. (LO 10.2) a. The ability to convert metric measurements to pounds, ounces, and inches (and from English to metric) facilitates understanding of childhood growth and development; a review could be integrated while explaining the slowing of growth velocity. b. The appropriate techniques for measuring growth are described. c. CDC growth charts (see http://www.cdc.gov/growthcharts/, with an example in Figure 10.1) are age- and gender-specific monitoring tools. d. When BMI is used to indicate overweight, providers evaluate children according to a percentile measure. e. The 95th percentile or greater indicates obesity, whereas a BMI below the 5th percentile indicates underweight. f. Overall patterns of growth and development are a better measure than small, short-term variations. g. Growth charts enable detection of patterns. h. Consistently accurate measurements lead to accurate monitoring. i. Common problems with measuring and plotting growth data are discussed. IV. Physiological and Cognitive Development Describe two strategies that parents/caretakers can employ to encourage toddlers/preschoolers to accept a variety of foods in their diets. (LO 10.3) a. Cognitive development, feeding skills and behaviors, appetite, satiety, and control of food intake are all discussed in this section. b. Appetite decreases after infancy.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 10: Toddler and preschooler nutrition

c. Toddlers and preschoolers have an innate ability to control energy intake. Arbitrary hunger or satiety cues, such as rewards for a clean plate, can train children to override that ability. d. Appetite and satiety studies with dietary preloads, using a variety of carbohydrates and fats, show that children adjust energy intake based on earlier consumption. e. This is one place to discuss portion size: get students to compare toddler-size portions (e.g., 1 Tbsp of food per year of age) to the portions they eat. f. This section provides an opportunity to link related material that describes stability in portion sizes and appetite self-regulation. g. Temperament differences between child and parent/caretaker also affect the feeding relationship. h. See Table 10.2 for examples of how young children can help in meal preparation. i. Suggestions for practical applications of research into child feeding are presented in Table 10.3. V. Energy and Nutrient Needs Explain what influences energy needs of young children. (LO 10.4) a. With increasing growth and age, calorie and protein needs decline relative to body weight and the decline in growth velocity. b. National surveys indicate that on average, most children meet targeted levels of nutrients, except for iron, calcium, and zinc. c. Table 10.4 lists estimated energy requirements for preschoolers; Table 10.5 lists DRIs for protein; and Table 10.6 lists DRIs for iron, zinc, and calcium. VI. Common Nutrition Problems Identify one common nutritional problem of young children and describe prevention strategies. (LO 10.5) a. Iron-deficiency anemia, dental caries, fluoride intake, constipation, lead poisoning, food security, and food safety are considered to be common nutritional problem areas. b. Incidence is associated with race and family income level. c. For example, iron-deficiency anemia is highest in African American and Mexican American children. d. The prevention and management of these problems are discussed. VII. Prevention of Nutrition-Related Disorders Define children who are overweight or those with obesity. (LO 10.6) a. Overweight, obesity, and cardiovascular disease prevention in children 2 to 5 years old are the focus in this section, and appropriate strategies are discussed. b. Early BMI rebound increases the risk of adult obesity.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 10: Toddler and preschooler nutrition

c. This section also addresses vitamin, mineral, and herbal supplements, offering guidance for use. VIII.

Dietary and Physical Activity Recommendations Describe the components of a healthy diet for young children as recommended by health and professional organizations and agencies. (LO 10.7)

a. This section answers the questions “What shall I feed my young child?” and “What is the proper level of activity for a young child?” b. Government-sponsored documents (such as the Dietary Guidelines 2020-2025 and the USDA’s MyPlate website) include physical activity advice for children. c. Furthermore, adaptations of dietary guidance tools have been published especially for children (see Figure 10.4). d. Specific nutrients to evaluate in a dietary assessment include iron, fiber (see Table 10.10), fat, and calcium, as well as fluids. e. Table 10.11 shows the mean intakes of the macronutrients (as a percentage of total energy) and cholesterol. f. Children eating vegetarian or vegan food patterns can grow and develop normally. g. Guidelines for physical activity are presented. IX. Nutrition Intervention for Risk Reduction Identify the basic premise upon which Bright Futures Nutrition is based. (LO 10.8) a. Bright Futures Nutrition is a model program “based on the premise that optimal nutrition for children should be approached from the perspective of the development of the child and put in the context of the environment in which the child lives.” b. Bright Futures provides many materials and resources that can be used to support a child’s development. X. Public Food and Nutrition Programs Identify one public food or nutrition program that provides services to young children and describe the program’s strategies in improving the nutrition of young children. (LO 10.9) a. The WIC program, a recurrent example of effective food programs in this text, serves children up to age 5. b. Other programs that also serve the nutritional needs of young children include the Farmers’ Market Nutrition Program (FMNP), Head Start, Early Head Start, and the Supplemental Nutrition Assistance Program. [return to top]

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 10: Toddler and preschooler nutrition

DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class. 1. The text states, “Children have an innate ability to adjust their caloric intake to meet energy needs.” Keeping that statement in mind, what do you see as some of the caretaker’s responsibilities providing the food for the child? What do you think about preparing different foods for various members of the household? (LO 10.3) 2. This chapter addresses cultural influences on eating habits (p. 281). Think about how you grew up and list some of the cultural norms that shaped your food habits as a child. (LO 10.7) 3. The growth charts (see http://www.cdc.gov/growthcharts/, also Figure 10.1) show a decrease in growth velocity after infancy. They are gender specific. What are the differences in patterns for males and females? Are birthweight averages reported by gender? Why might it be useful to use multiple indicators for tracking growth and development? Adult BMI, as a criterion for normal weight, is no longer reported by gender. Why? (LO 10.2) 4. Pretend you are planning a program for parents and their young children. Pick an age group from 2 to 6 and decide on session length. Use Table 10.2 to develop a participation class to teach meal preparation. What are some activities you might include? Remember that you want to foster an enjoyable atmosphere for parents and their young children. What do you consider to be the most important nutrition concepts to teach? Why? (LO 10.3) 5. What do you think about the use of food as a reward? Do you ever “treat” yourself by going out to eat or buying some special item (chocolate, a big latte, nachos at the ballgame)? Under what circumstance would you use (or not use) food as a reward for young children? (LO 10.3) 6. The temperament of a child and that of their caregiver may not match. What is the role of temperament clusters (easy, difficult, slow-to-warm-up) in the feeding relationship? How do you interpret the quotation “Better is a dinner of herbs where love is, than a fatted ox and hatred with it”? [Page 266 refers to the context in which food is offered. Context influences food preferences. Give an example of something you still like because of pleasant associations when you were a child, then have students provide their examples.] (LO 10.3) 7. Why is food safety an important issue for children? Describe strategies that work to decrease common food poisoning outbreaks. If you had a 3- to 5-year-old child living in your household, what could you do at home to role model habits that promote safe food? (LO 10.5) [return to top]

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 10: Toddler and preschooler nutrition

ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. The 2030 Healthy People Objectives (LO 10.1) Total Time: 20 minutes Have small groups examine the 2030 Healthy People objectives. Use Table 10.1 and have students discuss how each objective can be applied to toddlers and preschoolers. To help with the evaluation, ask students to make sure they understand how the outcome is defined, what measurements are needed in order to determine the outcome, and any possible issues that would arise when applying the objective to the population of toddlers and preschoolers. 2. Evaluating Daily Intake (LO 10.7) Total Time: Will vary Find a child between the ages of 2 and 5 (niece, nephew, friend, neighbor, family member) and get a record of their food intake during a 24-hour period. Evaluate the day’s intake using http://ChooseMyPlate.gov. What were the positive aspects of using this dietary assessment tool? What did you find difficult about using MyPlate? What are issues to be addressed when doing dietary assessments with young children? [Parent needs to be involved, portion size estimates, etc.] 3. “Tips for Feeding Young Children” (LO 10.7) Total Time: 30 minutes The New Mexico State University offers a consumer information brochure titled “Tips for Feeding Young Children (Guide E-134)” at http://aces.nmsu.edu/pubs/_e/E134.pdf. Assign a student to respond to each of the guidelines described that promotes a better eating environment for children. For example, according to the Cooperative Extension Service, “Children have small stomachs and need to eat several times throughout the day. Provide small meals and snacks to maintain a consistent supply of energy and nutrients for growth and activity.” What are the pros and cons of this recommendation? Another example under “Making Mealtimes Pleasant” is “Two-year-olds may stay with a meal for as long as 10 minutes; four-year-olds are usually ready to leave the table in 20 minutes.” Does this mean that family time around the meal table should be changed? 4. Being a Good Role Model (LO 10.3) Total Time: 30 minutes What can a parent do to role model eating a variety of foods for their young children? For example, it can take 8–10 exposures to a new food for a child to accept or even like the new food. Have students pair up and generate some strategies that might promote or increase dietary variety. Then have the students role-play the parent–child dyads to try to institute one or two of their strategies. 5. Complete Worksheet 10-1: Case Study—Monitoring Growth and Development (LO 10.2) Total Time: 20–30 minutes Answer Key: 1. See below for the answers.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 10: Toddler and preschooler nutrition

Date

Weig ht

Heig h t

32 lb

Weight for Age (percent ile) 50th

Third birthd ay Fourth birthd ay 4.5 years old

42 lb

85th

5 years old

45 lb

80th

Height for Age (percent ile) 37 in. 45th

40 lb

80th

40 in . 40.5 in . 41 in.

50th 25th 20th

BMI

BMI for age (percent ile)

16.4 kg/ m2 17.5 kg/ m2 18.0 kg/ m2 18.8 kg/ m2

60th 92nd >95th >95th

2. Obese 3. His height is decreasing in growth channels. 4. Answers will vary but might include looking for ways to increase his level of physical activity and decrease his access to snack foods.

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 10: Toddler and preschooler nutrition

Worksheet 10-1: Case Study—Monitoring Growth and Development (LO 10.2) Dave is a 5-year-old male who was referred to a pediatric dietitian due to his pediatrician’s concerns with his weight gain over the past year. His parents recently divorced, and both parents have equal custody. Dave has unlimited access to snacks at both parents’ homes, and his favorite pastimes include watching cartoons and playing video games with his brothers. Date

Third birthda y Fourth birthda y 4.5 years old 5 years old

Weigh t

Weight for Age (percentile )

Heigh t

32 lb

37 in.

40 lb

40 in.

42 lb

40.5 in. 41 in.

45 lb

Height for Age (percentile )

BM I

BMI for Age (percentile )

Questions: 1. Complete the above table with BMI and growth chart data (see http://www.cdc.gov/growthcharts/ for growth charts).

2. What is the current status of Dave’s weight according to his BMI for age percentile?

3. Do you have any other concerns about Dave’s growth based on the data in the above table?

4. What suggestions do you have for helping Dave’s parents decrease his risk of illness related to his weight? [return to top]

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 10: Toddler and preschooler nutrition

ADDITIONAL RESOURCES INTERNET RESOURCES •

Science of nutrition •

American Academy of Pediatrics: http://www.aap.org

•

Academy of Nutrition and Dietetics: http://www.eatright.org

•

Diabetes Care and Education (a dietetic practice group of the Academy of Nutrition and Dietetics): http://www.dce.org/

•

National Academies of Science, Engineering & Medicine Health and Medicine Division: http://www.nationalacademies.org/hmd/

•

National Academies Press, Dietary Reference Intakes: http://www.nap.edu/topics.php?topic=380

•

Toddler and preschool nutrition •

National Institute for Early Education Research (NIEER): https://nieer.org

•

About Health for Pediatrics: http://pediatrics.about.com/

•

WebMD’s Fit Kids BMI Calculator: http://www.webmd.com/parenting/raisiting-fit-kids/weight/bmi/bmicalculator

•

Public food and nutrition programs •

Bright Futures: http://www.brightfutures.org/

•

Partnership for Food Safety Education: http://www.fightbac.org

•

USDA’s MyPlate: http://www.choosemyplate.gov/

Nationwide priorities and nutritional health: United States •

Centers for Disease Control and Prevention, National Center for Health Services, CDC Growth Charts: http://www.cdc.gov/growthcharts/

•

Department of Agriculture, Center for Nutrition Policy and Promotion: http://www.cnpp.usda.gov/

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 10: Toddler and preschooler nutrition

•

National Center for Complementary and Integrative Health, National Institutes of Health: http://nccih.nih.gov/

•

Supplemental Nutrition Assistance Program: http://www.fns.usda.gov/ops/research-and-analysis

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 11: Toddler and Preschooler nutrition: Conditions and Interventions

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 11: TODDLER AND PRESCHOOLER NUTRITION : CONDITIONS AND INTERVENTIONS

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 4 Chapter Outline ................................................................................................................... 4 Discussion Questions.......................................................................................................... 7 Additional Activities and Assignments .............................................................................. 8 Additional Resources ........................................................................................................ 14 Internet Resources.................................................................................................................. 14

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to demonstrate how nutrition assessments, diagnoses, and interventions complement medical diagnoses and medical treatment. This chapter discusses children who do not fit the typical pattern, children with special health care needs associated with a chronic condition or disability, and children who are at risk. The chapter will cover nutrition needs and services for young children with autism spectrum disorder (ASD), food allergies, breathing or pulmonary problems, feeding and growth problems, and developmental delays, as well as those at risk for needing nutritional intervention.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 11.1

Differentiate the similarities and differences in young children with and without special healthcare needs.

11.2

Identify the more common nutrition problems in young children with special healthcare needs that result from chronic health conditions.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 11: Toddler and Preschooler nutrition: Conditions and Interventions

11.3

Recognize approaches for completing a growth assessment in young children with special healthcare needs.

11.4

Describe how feeding difficulties in preschoolers and toddlers are included in nutrition assessments and interventions.

11.5

Identify conditions in young children with special needs in which nutrition services are a part of medical management.

11.6

Review food allergy and intolerance consequences for young children.

11.7

Describe the concerns with the use of dietary and herbal remedies in young children with special healthcare needs.

11.8

Explain how families access community and regional resources that provide nutrition services for toddlers and preschoolers with chronic health problems.

11.9

Review some of the nutritional concerns due to the COVID-19 pandemic.

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KEY TERMS Children with special healthcare needs: A general term for infants and children with, or at risk for, physical or developmental disabilities or chronic medical conditions from genetic or metabolic disorders, birth defects, premature births, trauma, infection, or prenatal exposure to drugs. Chronic condition: Disorder of health or development that is the usual state for an individual and unlikely to change, although secondary conditions may result over time. Pulmonary: Related to the lungs and their movement of air for exchange of carbon dioxide and oxygen. Early intervention services: Federally mandated evaluation and therapy services for children in the age range from birth to 3 years under the Individuals with Disabilities Education Act. Rett syndrome: Condition in which a genetic change on the X chromosome results in severe neurological delays, causing children to be short, thin-appearing, and unable to talk. Meningitis: Viral or bacterial infection in the central nervous system, which causes inflammation of the membranes covering the brain and spinal cord that is likely to

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 11: Toddler and Preschooler nutrition: Conditions and Interventions

cause a range of long-term consequences in infancy, such as intellectual disability, blindness, and hearing loss. Intellectual disability: Substantially below-average intelligence and problems in adapting to the environment and the person’s ability to learn at an expected level and function in daily life which emerge before age 18 years. Attention deficit hyperactivity disorder (ADHD): Condition characterized by low impulse control and short attention span, with and without high level of overall activity. Neuromuscular disorders: Conditions of the nervous system characterized by difficulty with voluntary or involuntary control of muscle movement. Hypotonia: Condition characterized by low muscle tone, floppiness, or muscle weakness. Hypertonia: Condition characterized by high muscle tone, stiffness, or spasticity. Medical home: The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. Medical neglect: Failure of parent or caretaker to seek, obtain, and follow through with a complete diagnostic study or medical, dental, or mental health treatment for a health problem, symptom, or condition that, if untreated, could become severe enough to present a danger to the child. Prader-Willi syndrome: Condition in which partial deletion of chromosome 15 interferes with control of appetite, muscle development, and cognition. Most cases of Prader-Willi syndrome occur when a segment of the paternal chromosome 15 is deleted in each cell. Autism spectrum disorders (ASDs): A group of developmental disorders characterized by deficits in communication, social interaction, and behaviors that meet diagnostic criteria in standardized testing, with onset generally before age 3. Spastic quadriplegia: A form of cerebral palsy in which brain damage interferes with voluntary muscle control in both arms and legs. Gastrostomy: Form of enteral nutrition support for delivering nutrition by tube directly into the stomach, bypassing the mouth, through a surgical procedure that creates an opening through the abdominal wall and stomach. Asthma: Condition in which the lungs are unable to exchange air due to lack of expansion of air sacs. It can result in a chronic illness and sometimes unconsciousness and death if not treated.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 11: Toddler and Preschooler nutrition: Conditions and Interventions

Bronchopulmonary dysplasia (BPD): Condition in which the underdeveloped lungs in a preterm infant are damaged so that breathing requires extra effort. Work of breathing (WOB): A common term used to express extra respiratory effort in a variety of pulmonary conditions. Anaphylaxis: Sudden onset of a reaction with milk to severe symptoms, including a decrease in ability to breathe, wheezing, coughing or tightness in chest, which may be severe enough to cause a coma. [return to top]

WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • • • • •

Updated information on children with special health needs Strengthened section on avoidant restrictive food intake disorder (ARFID) Additional information on celiac disease Expanded section on asthma, including at-risk ethnic groups Additional information on parents’ self-diagnosis of food allergies in their children and implications New section on COVID-19 pandemic

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CHAPTER OUTLINE I.

Introduction a. This chapter addresses the small percentage of toddlers and preschoolers who have special health care needs. b. Parents, teachers, and care providers may suspect problems before chronic conditions are diagnosed. c. The Healthy People 2030 (Chapter 10, Table 10.1) objectives and the 2020–2025 U.S. Dietary Guidelines haven’t been customized to children with special health care needs.

II. Who Are Children with Special Health Care Needs? Differentiate the similarities and differences in young children with and without special healthcare needs. (LO 11.1) a. Childhood disability prevalence estimates range widely from 5% to 31% of children. b. Of children with disabilities, 90% have some nutritional problem.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 11: Toddler and Preschooler nutrition: Conditions and Interventions

c. Criteria for early intervention services are bulleted on page 288. d. Service provision is regulated under several federal programs, including social security and IDEA. III. Nutrition Needs of Toddlers and Preschoolers with Chronic Conditions Identify the more common nutrition problems in young children with special healthcare needs that result from chronic health conditions. (LO 11.2) a. The DRIs for toddlers and preschoolers are a good place to start when assessing the nutrient needs for children with special health care needs; some modifications might be needed (e.g., fiber). b. Overweight can exacerbate existing conditions such as Down syndrome; therefore, preventing overweight is one focus for nutrition intervention. Promoting growth is the other main focus. c. The statement “Underweight results in part from the chronic illness and its medical treatment” provides an opportunity to delineate nutrition and developmental issues in healthy children and those with special needs. d. Table 11.3 offers an overview of conditions that require either higher or lower caloric intakes. e. This section emphasizes individualized diets. IV. Growth Assessment Recognize approaches for completing a growth assessment in young children with special healthcare needs. (LO 11.3) a. A great example of how specialized charts are used to track growth (or lack thereof) is presented in Figure 11.1, the Nellhaus head circumference growth chart. b. Questions bulleted on page 290 help to identify the need for nutrition services in conditions such as failure to thrive and celiac disease. V. Feeding Problems Describe how feeding difficulties in preschoolers and toddlers are included in nutrition assessments and interventions. (LO 11.4) a. All children face common developmental issues related to feeding. b. These issues are exacerbated when chronic conditions and behavioral problems exist. c. Feeding problems can include issues surrounding excessive fluid intake, food safety, and disabilities involving neuromuscular control. d. Chronological age alone is not an adequate guide to solve feeding issues. VI. Nutrition-Related Conditions: Failure to Thrive Identify conditions in young children with special needs in which nutrition services are a part of medical management. (LO 11.5)

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 11: Toddler and Preschooler nutrition: Conditions and Interventions

a. The text case studies are designed to help learners understand the complexities of good nutrition for sick children. b. The major conditions discussed in this section are failure to thrive, toddler diarrhea, celiac disease, autism, muscle coordination problems and cerebral palsy, pulmonary problems, and developmental delays. VII. Food Allergies and Intolerance Review food allergy and intolerance consequences for young children. (LO 11.6) a. A child’s whole family is affected by food allergies or intolerances, and most students probably have some experience or knowledge of diets limited because of a food allergy. b. Prevalence estimates are fairly broad: true allergies exist in 2–8% of children. c. Examples of foods that may cause anaphylaxis for some children are listed on page 299. d. Compare this list against dietary guidance tools such as the USDA’S MyPlate website: how is the definition of variety changed (or is it) when a child has true allergies? VIII.

Dietary Supplements and Herbal Remedies Describe the concerns with the use of dietary and herbal remedies in young children with special healthcare needs. (LO 11.7)

a. Supplements may feed the hope that all families have for their children, no matter what their health status. b. The families who are most vulnerable to using inappropriate products are those for whom treatments do not seem to be working. c. Advice from medical and nutrition service providers can help families sort through evidence in order to identify potentially effective products and avoid potentially harmful ones. IX. Sources of Nutrition Services Explain how families access community and regional resources that provide nutrition services for toddlers and preschoolers with chronic health problems. (LO 11.8) a. Programs to foster children’s nutritional health are listed on page 300 and are also described in Chapters 8 and 10. X. COVID-19 Pandemic Review some of the nutritional concerns due to the COVID-19 pandemic. a. It is currently unknown to what level the COVID-19 pandemic will impact the nutritional status of children around the globe.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 11: Toddler and Preschooler nutrition: Conditions and Interventions

b. The pandemic has increased the risk for malnutrition, obesity, undernutrition, and hidden hunger due to micronutrient deficiencies, especially in groups of children who are vulnerable.

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DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class. 1. List three examples of childhood disabilities that affect nutritional status. How might each named disability affect (1) food intake and (2) nutritional status? (LO 11.1) 2. A diagnosis tends to label a child. For example, think about your own response if you were introduced to a youngster with one of the following lines: “PJ is the goalie on our hockey team,” “PJ likes to read mystery books,” or “PJ has diabetes.” What are the pros and cons of early diagnosis when a health problem affecting standard development is suspected? (LO 11.2) 3. The American Academy of Pediatrics (AAP) recommends that 1- to 6-year-old children limit fruit juice intake to 4–6 fluid ounces per day. Why is this a good idea? What suggestions could you make to parents who are trying to encourage their child to consume more fruits and vegetables, but have now been told to limit the fruit juice? (LO 11.4)

4. What was the last new food that you, as an adult, tried? In the last six months, what new foods or beverages did you try? When it comes to expanding the number or types of food eaten, how is the advice for children with self-restricted diets typical of autism (adding one new food by offering it 15 to 20 times over a one- to two-month period) different from or similar to that for children in general? (LO 11.4) 5. Spastic quadriplegia is a form of cerebral palsy affecting muscle control. Describe a growth assessment for a child with suspected cerebral palsy. How will the assessment outcome affect feeding strategies? (LO 11.3) 6. “It is better to take food into the mouth than to take worries into the heart” (p. 299). What does this Yiddish saying mean in the context in which it is used? Can

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 11: Toddler and Preschooler nutrition: Conditions and Interventions

you think of other sayings that have similar meanings? Do you agree or disagree with this message? Why? (LO 11.7) [return to top]

ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. Programs and Services for Intellectual and Developmental Disabilities (LO 11.8) Total Time: 30 minutes Distribute or display the position statement from the Academy of Nutrition and Dietetics on Nutrition Services for Individuals with Intellectual and Developmental Disabilities and Special Health Care Needs, which is available from: https://www.jandonline.org/article/S2212-2672(15)00121-5/abstract Review the programs and services available for individuals with intellectual and developmental disabilities in Figure 1, and common nutrition-related issues in Figure 2. Have the class divide into groups and, using information at the end of the article, come up with recommendations for (1) areas for special training needed by nutrition professionals in working with this population, (2) collaboration with other professions, and (3) incorporation of the medical home model in provision of care. 2. Resources for Taking Care of a Child with Chronic and Complex Conditions (LO 11.8) Total Time: 30 minutes Have students explore the Medical Home Portal at http://www.medicalhomeportal.org. The “For Parents & Families” tab contains resources and guidelines for taking care of a child with chronic and complex conditions. Divide the class into small groups, and assign each group a specific diagnosis and condition (see the FAQ tab on the left) to develop suggestions for families specific to that condition. These suggestions can include treatments, impact on family, resources, referrals to other professionals, and so on. Each group should summarize their findings for the class. 3. Analyze the Growth Chart (LO 11.3) Total Time: 20 minutes Analyze the information presented in the growth chart in Figure 11.1. When did the girl drop off her growth curve? By how many percentile points did she drop before an intervention was begun? What are the recommendations about the percentile changes necessary before an intervention is begun? What can you say about the weight gain? Would you expect different criteria among children who receive Medicaid, those on private insurance programs, and those belonging to health maintenance organizations? Why or why not? 4. Complete Worksheet 11-1: Case Study—Monitoring Growth and Development in a Child with Multiple Food Allergies (LO 11.3) Total Time: 25 minutes

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 11: Toddler and Preschooler nutrition: Conditions and Interventions

Answer Key: 1. His height is below average for his age, but he appears to be growing appropriately. Date

Weight

Weight for Age %

Height

Height for Age %

Weight for Length %

12 months

23 lb

55th

29 in.

25th

92nd

18 months

26 lb

50th

31.5 in.

25th

85th

24 months

29 lb

60th

33.5 in.

25th

90th

2. His juice intake should be reduced, and he needs to be consuming 16 ounces of fortified soy milk daily. 3. Yes. 4. Adequacy of calcium and vitamin D intake needs to be monitored, as cow’s milk is a major source of these nutrients in a child’s diet. Soy milk is appropriate as long as it’s fortified. 5. Justin’s family, caregivers, and the staff at his preschool need to have access to, and know how to use, an epinephrine pen. 5. Complete Worksheet 11-2: Case Study—Weight Plateau (11.4) Total Time: 20 minutes Answer Key: 1. Gayle probably did feel hungry but was too overwhelmed by her circumstances to handle her own emotions. She was too young to be able to express her strong feelings. 2. Children can sometimes adapt faster than adults, but it may be a short- or long-term impact. At other times in her life, she may refuse to eat if she is very upset. 3. The nutritional adequacy of one food is not too important if the diet is so unbalanced. The juice was a comfort food, but could not meet all her nutritional needs regardless of type.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 11: Toddler and Preschooler nutrition: Conditions and Interventions

Worksheet 11-1: Case Study—Monitoring Growth and Development in a Child with Multiple Food Allergies (LO 11.3) Justin is a 24-month-old male with multiple food allergies, including milk, eggs, and peanuts. When he was 6 months old, a cooking utensil that had been used to cook eggs touched his arm, and his mother noticed a significant dermatological response. As a result, Justin’s pediatrician advised her to avoid eggs, cow’s milk, and peanuts in Justin’s diet until food allergy testing could be done at 2 years of age. Fortunately, Justin hasn’t had any negative reactions to soy milk. Food allergy testing has confirmed that Justin needs to continue to avoid cow’s milk and peanuts. His pediatrician plans to conduct food allergy testing annually and advises his mother that Justin will likely outgrow the milk allergy. Justin is referred to a registered dietitian for an assessment of his growth and nutrition intake. His mother reports that he is able to feed himself and she has noticed no problems with chewing and swallowing. A 24-hour dietary recall shows Justin consumed the following foods:

Fortified soy milk (4 ounces), rice cereal, bananas, grilled soy-cheese sandwich, fortified soy milk (4 ounces), green beans, apricots, orange juice (8 ounces), apple slices, almond butter on toast, apple juice (8 ounces), roast turkey, baked potato, green peas, and fortified soy milk (4 ounces).

Weight for Age %

Date

Weight

Height

12 months

23 lb

29 in.

18 months

26 lb

31.5 in.

24 months

29 lb

33.5 in.

Height for Age %

Weight for Length %

Questions (from the “Growth Assessment” section on page 286): 1. Complete the above table. Is Justin’s growth on track? (See http://www.cdc.gov/growthcharts/ for growth charts.)

2. Is Justin’s diet adequate?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 11: Toddler and Preschooler nutrition: Conditions and Interventions

3. Are Justin’s eating and feeding skills appropriate for his age?

4. Does the diagnosis affect his nutritional needs?

5. As Justin is getting ready to start preschool soon, what safety concerns do his parents need to be aware of?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 11: Toddler and Preschooler nutrition: Conditions and Interventions

Worksheet 11-2: Case Study—Weight Plateau (11.4) A 2.5-year-old girl, Gayle, was seen at the clinic with her 22-year-old mother, the child’s aunt, and a young cousin. She was developing normally but had not gained weight for more than 4 months. The pediatrician did not find a medical basis for the weight plateau. She was offered appropriate foods in appropriate serving sizes, but she mostly was throwing it on the floor or refusing it with crying tantrums. She liked to drink juice from her sippy cup throughout the day. She carried the cup with her most of the time. The family was sure it was not enough for her, and they did not limit her intake because she ate little else. Eventually, the aunt mentioned how the girl used to eat well at her grandparents’ house. With sensitive review of the child’s social history, it became clear that the child had been living with her grandparents while the mother was incarcerated. Her mother had cared for her until 8 months of age. Gayle then went to live with her grandparents until her mother's release, at which time she and her mother moved into their own apartment. Gayle had not seen her grandparents for the last several months.

Assessment and recommendation: After confirming no nutritional or medical basis for the issues, family disruption was considered the basis for the weight plateau, as a result of interfering with Gayle’s hunger and appetite. The change in Gayle’s eating coincided with a time of sudden change in her life. From the child’s viewpoint, her grandparents and their home were suddenly replaced by a new person and a new setting.

Gayle’s mother was referred to the local early intervention program, which had parenting classes to help her meet the emotional and social needs of her daughter. She was encouraged to view Gayle’s eating refusals as a sign of her adjustment to her new home. Gayle’s food refusals and mealtime behaviors lessened as she felt more secure with her mother in their new home. Gayle’s mother met with the registered dietitian about how to reinforce Gayle’s eating and how to balance the amount of juice and other fluids she drank with solid foods to gain weight.

1. Why didn’t Gayle feel hungry?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 11: Toddler and Preschooler nutrition: Conditions and Interventions

2. How long will it take for Gayle to return to her usual eating pattern?

3. How important is the nutrient value of the juice selected?

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 11: Toddler and Preschooler nutrition: Conditions and Interventions

ADDITIONAL RESOURCES INTERNET RESOURCES •

General nutrition •

Quackwatch (nonprofit corporation whose purpose is to combat health-related frauds, myths, fads, and fallacies): http://www.quackwatch.com

•

Nutriwatch (Quackwatch is subdivided by topics; to go directly to the food and nutrition information, use this link): http://www.nutriwatch.org/

•

Science of nutrition •

PubMed home: http://www.ncbi.nlm.nih.gov/pubmed

•

The National Academies of Sciences, Engineering & Medicine Health and Medicine Division: http://www.nationalacademies.org/hmd/

•

Toddler and preschooler nutrition: Conditions and interventions •

Federation for Children with Special Needs: http://fcsn.org/index.php

•

FARE (Food Allergy Research & Education): http://www.foodallergy.org

•

Center for Parent Information and Resources: https://www.parentcenterhub.org

•

NORD (National Organization for Rare Disorders): http://www.rarediseases.org

•

The National Down Syndrome Society: http://www.ndss.org

Public food nutrition programs •

National Association of Councils on Developmental Disabilities: http://www.nacdd.org/home/

•

Nationwide priorities and nutritional health •

American College of Sports Medicine: http://www.acsm.org

•

United States •

U.S. Department of Agriculture Center for Nutrition Policy and Promotion: http://www.cnpp.usda.gov/

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 11: Toddler and Preschooler nutrition: Conditions and Interventions

•

The Center for Health and Health Care in Schools: http://www.healthinschools.org

•

Canada •

Government of Canada. Well-Being of Canada’s Young Children: Government of Canada Report 2003 (Chapter 6: Young Children with Disabilities in Canada): http://www.dpe-agje-ecd-elcc.ca/eng/ecd/wellbeing/sp_1027_04_12_eng.pdf

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 12: Child and preadolescent nutrition

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 12: CHILD AND PREADOLESCENT NUTRITION

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 3 Chapter Outline ................................................................................................................... 3 Discussion Questions.......................................................................................................... 6 Additional Activities and Assignments .............................................................................. 7 Additional Resources .........................................................................................................13 Internet Resources.................................................................................................................. 13

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to discuss the impact of nutritional status on the growth and development of school-age and preadolescent children. The chapter will define the stages of middle childhood and preadolescence. Adequate nutrition continues to play an important role in ensuring children reach their full potential for growth, development, and health during the school-age years. Meeting energy and nutrient needs, addressing common nutrition problems, and preventing nutritionrelated disorders will be discussed later in the chapter.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 12.1

List two Healthy People 2030 objectives that specifically relate to middle childhood and preadolescence.

12.2

Describe the expected pattern of growth of a healthy child during middle childhood and preadolescence.

12.3

Define BMI rebound and describe the consequences of early BMI rebound.

12.4

Explain what influences energy needs of school-age children.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 12: Child and preadolescent nutrition

12.5

List two strategies for preventing dental caries in school-age children.

12.6

Describe prevention strategies for overweight/obesity in school-age children.

12.7

Describe the components of a healthy diet during middle childhood and preadolescence as recommended by health and professional organizations and agencies.

12.8

List two strategies that parents/caretakers can employ to encourage school-age children to be more physically active.

12.9

List three strategies that school health programs can use to promote healthy eating.

12.10

Describe one component of the USDA’s Child Nutrition Program and explain how this specific program addresses the health of school-age children.

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KEY TERMS Middle childhood: Children between the ages of 5 and 10 years; also referred to as “school-age.” Preadolescence: The stage of development immediately preceding adolescence; 9–11 years of age for girls and 10–12 years of age for boys. Bone age: Bone maturation; correlates well with stage of pubertal development. Resting energy expenditure: The amount of energy needed by the body in a state of rest. Total fiber: Sum of dietary fiber and functional fiber. Dietary fiber: Complex carbohydrates and naturally occurring lignins; found mainly in the plant cell wall. Dietary fiber cannot be broken down by human digestive enzymes. Functional fiber: Nondigestible carbohydrates including plant, animal or commercially produced sources that have beneficial effects in humans. Pouring rights: Contracts between schools and soft-drink companies, whereby the schools receive a percentage of the profits of soft-drink sales in exchange for the school offering only that soft-drink company’s products on the school campus. Competitive foods: Foods sold to children in food service areas during mealtimes that compete with the federal meal programs.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 12: Child and preadolescent nutrition

Commodity program: A USDA program in which food products are sent to schools for use in child nutrition programs. Commodities are usually acquired for farm price support and surplus-removal reasons.

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WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • • • • • • • •

Updated statistics related to children living in poverty and without health insurance Updated DRI for energy for children and preadolescents Healthy People 2030 Objectives related to school-aged children American Academy of Pediatrics 2020 policy statement on digital advertising to school-aged children Data about dietary intake of school-aged children related to Dietary Guidelines for Americans 2020–2025 Most recent Academy of Nutrition and Dietetics position paper on treatment of pediatric overweight and obesity Data on the relationship between soft drink consumption, BMI, and trends in sugar-sweetened beverage intake Updated information on nutrition education in schools Information on the impact of the COVID-19 pandemic on the food security of school-aged children

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CHAPTER OUTLINE I.

Introduction a. Middle childhood is the period from ages 5–10 years for girls and boys, but after age 10, gender affects classification. b. Preadolescence is defined as ages 9–11 for girls and 10–12 for boys. c. Adequate nutrition during these years prepares children for the adolescent growth spurt so that they reach their full growth potential. d. Good nutrition also enhances academic performance.

II. Tracking Child and Preadolescent Health

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 12: Child and preadolescent nutrition

List two Healthy People 2030 objectives that specifically relate to middle childhood and preadolescence. (LO 12.1) a. Table 12.1 displays Healthy People 2030 nutrition and physical fitness objectives related to school-age children. b. The objectives address topics that include overweight and obesity, dietary intake, and physical activity. Statistics on progress are compared to baseline and target data. III. School-Age Growth and Development Describe the expected pattern of growth of a healthy child during middle childhood and preadolescence. (LO 12.2) a. The 2000 CDC growth charts (http://www.cdc.gov/growthcharts/) “are the recommended tool for monitoring the growth of a child” (p. 304). b. Figures 12.1 and 12.2 can be used to track individuals from ages 2 to 20. c. Growth pattern deviations are cause for further assessment and evaluation. IV. Physiological and Cognitive Development of School-Age Children Define BMI rebound and describe the consequences of early BMI rebound. (LO 12.3) a. An increase in percent body fat, the “BMI rebound, or adiposity rebound” typically occurs near age 6. b. It is reflected in the BMI-for-age growth charts, where one can see that females have a higher percentage of body fat than males. c. The cognitive development tasks during this time focus on achieving selfefficacy and learning concrete operations. d. Children master the use of eating utensils and can participate in simple food preparation, taking some responsibility for mealtime chores. e. Although peer and outside influences start to gain strength, parents and older siblings are still the most influential role models for food and eating behaviors. f. Mothers with restrictive eating practices model those dieting behaviors for children. V. Energy and Nutrient Needs of School-Age Children Explain what influences energy needs of school-age children. (LO 12.4) a. As relative growth slows, the energy and protein DRIs continue to decline relative to body weight. b. For the most part, vitamin and mineral requirements increase. c. Values are listed inside the front cover and in Table 12.2. VI. Common Nutrition Problems List two strategies for preventing dental caries in school-age children. (LO 12.5)

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 12: Child and preadolescent nutrition

a. Iron-deficiency anemia and dental caries, common nutrition problems in school-age children, are discussed in this section. VII. Prevention of Nutrition-Related Disorders in School-Age Children Describe prevention strategies for overweight/obesity in school-age children. (LO 12.6) a. Two conditions are covered: (1) overweight and obesity and (2) cardiovascular disease. b. According to NHANES data, the national rise in prevalence of overweight and obesity is associated with “significant changes in dietary intake of school-age children” combined with declines in physical activity. c. Predictors of overweight and obesity are reflected in the 2030 Healthy People objectives. d. Staged obesity treatment for children aged 6–11 is described in Figure 12.3. e. For heart disease prevention, the joint recommendations for children prepared by the American Heart Association and the American Academy of Pediatrics are covered on pp. 315–316. VIII.

Dietary Recommendations Describe the components of a healthy diet during middle childhood and preadolescence as recommended by health and professional organizations and agencies. (LO 12.7)

a. Iron, total fiber (Table 12.7), fat, calcium, and vitamin D are highlighted. b. Quantity and type of fluid intake among school-age children is also discussed. c. Soft drinks are a special concern in the diets of children, as more and more children consume sweetened beverages. d. Studies have linked the consumption of soft drinks to an increase in overweight. e. Dietary patterns vary by culture and other lifestyle choices. f. This section addresses child nutrition from several cultural perspectives. g. Occasionally, children adopt a no-meat eating pattern even when the family eats meat, fish, and poultry. IX. Physical Activity Recommendations List two strategies that parents/caretakers can employ to encourage school-age children to be more physically active. (LO 12.8) a. The recommendation for children is at least 60 minutes, every day! b. School and neighborhood safety, physical education programs in schools, and time spent with television and inactive games are some of the factors influencing activity levels. c. The AAP recommendations for organized sports are listed on pp. 322–323.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 12: Child and preadolescent nutrition

X. Nutrition Intervention for Risk Reduction List three strategies that school health programs can use to promote healthy eating. (LO 12.9) a. Recommendations and model programs are presented to illustrate how intervention strategies can work. b. Nutrition integrity in schools is supported by USDA regulations, and several model programs have demonstrated how children’s nutritional intake can be enhanced. c. Table 12.8 provides requirements for school wellness policies for the promotion of overall health. XI. Public Food and Nutrition Programs Describe one component of the USDA’s Child Nutrition Program and explain how this specific program addresses the health of school-age children. (LO 12.10) a. Best known are the National School Lunch Program, the School Breakfast Program, Summer Food Service, and Team Nutrition. These are only some of the public programs seeking to enhance childhood nutritional status and thereby health. b. Table 12.9 provides the USDA meal pattern for school lunches, and Table 12.10 provides the meal pattern for school breakfasts.

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DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class. 1. What factors most influenced your eating habits during childhood? For example, did access to food, poverty, or unemployment of caregivers affect what and when you ate? (LO 12.1)

2. Obesity and overweight in children are defined differently than for adults (i.e., BMI for age vs. BMI of 30 or greater) (see p. 304). Children are classified as either overweight or obese. What are some possible reasons for using BMI for age to assess children? (LO 12.2)

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 12: Child and preadolescent nutrition

3. Requires homework: Examine a newspaper or magazine or track another media channel to find examples of how food products are marketed to children (e.g., breakfast cereals shaped like cartoon characters). For class discussion: What are the messages being conveyed? Who is targeted by these messages? If you were a parent of a child aged 5 to 12 years old, how would this information affect your job of providing a healthy diet for your family? (LO 12.3)

4. Suggest some snacks that would meet the nutritional needs of children for iron, calcium, and fiber. [Chapter 1 presents lists for foods containing these nutrients.] Now that you have developed this list of suggested foods, evaluate each item for food safety: how safe is each food to bring to a soccer game or for a class snack? Discuss the occasionally conflicting criteria about what makes a “good snack.” (LO 12.7)

5. Why was NHANES III data regarding the prevalence of overweight in children not included in the revised growth charts (pp. 304-305)? (LO 12.2)

6. Examine the vitamin and mineral requirements of children aged 4–8 and 9–13. How are they different from requirements up to age 4? Which requirements increase and which decrease with increased age? (LO 12.4)

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ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. Dive into Recent Research to Discuss Factors Affecting Childhood Obesity (LO 12.3) Total Time: Will vary Have students locate and read a recent research article about the contribution of fast foods, sweetened beverages, or screen time to childhood obesity and prepare to discuss the results of the research in class. 2. National School Lunch Program Standards (LO 12.9) Total Time: 30 minutes The National School Lunch Program Standards state the following about a grain serving: “Beginning July 1, 2012 (SY 2012–2013), half of the grains offered during the school week must meet the whole grain-rich criteria specified in FNS guidance. Beginning July 1, 2014 (SY 2014–2015), all grains must meet the whole grain-rich criteria specified in FNS guidance. … Schools may count up to two grain-based desserts per week towards meeting the grains requirement as

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 12: Child and preadolescent nutrition

specified in FNS guidance” (7 CFR Part 210, available from http://www.govinfo.gov/content/pkg/FR-2012-01-26/pdf/2012-1010.pdf). Have students discuss their views on how the National School Lunch Program has attempted to apply the Dietary Guidelines. See Table 12.9 for food-based menu planning guidelines.

3. Model School Wellness Policies (LO 12.10) Total Time: 25 minutes Visit the Model School Wellness Policies website (http://www.schoolwellnesspolicies.org/) and find an example of a policy designed to encourage healthy eating. What is that policy? What are the expected health outcomes from better nutritional habits? Are the nutrition effects on health outcomes clearly documented? If you were to give the policy designers feedback, what would you want them to know? 4. Complete Worksheet 12-1: Case Study—Treatment of Overweight and Obesity in Childhood (LO 12.6) Total Time: 20 minutes Answers: 1. 17.9 kg/m2 and 92nd percentile; she is classified as overweight. 2. Readiness to change, frequency of eating away from home and fast food, consumption of sweetened beverages (including fruit juice), usual portion sizes consumed, breakfast consumption, consumption of foods high in energy density, consumption of fruits and vegetables, frequency of meals and snacks. 3. Stage 1: Prevention Plus protocol. Recommendations are listed in the report. 4. 19.5 kg/m2 and >95th percentile; she is classified as obese. 5. Stage 2: Structured Weight Management Protocol. Recommendations are listed in the report. 6. Stage 3: Comprehensive Multidisciplinary Protocol and Stage 4: Tertiary Care Protocol; recommendations are in the report.

5. Complete Worksheet 12-2: Calculate Energy and Protein Needs for Children and Preadolescents (LO 12.4) Total Time: 30 minutes Answers: 1. EER = 88.5 − (61.9 × age [y]) + PA × (26.7 × weight [kg] + 903 × height [m]) + 20 kcal EER = 88.5 − (61.9 × 4.5) + 1.0 × (26.7 × 17.3 + 903 × 0.99) + 20 kcal = 1186 calories

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 12: Child and preadolescent nutrition

0.95 g protein/kg/day = 0.95 g × 17.3 kg = 16.4 grams protein

2. EER = 135.3 − (30.8 × age [y]) + PA × (10.0 × weight [kg] + 934 × height [m]) + 20 kcal EER = 135.3 − (30.8 × 5) + 1.26 × (10.0 × 19.1 + 934 × 1.1) + 20 kcal = 1536 calories 0.95 g protein/kg/day = 0.95 g × 19.1 kg = 18.1 grams protein

3. EER = 135.3 – (30.8 × age [y]) + PA × (10.0 × weight [kg] + 934 × height [m]) + 25 kcal EER = 135.3 – (30.8 × 10) + 1.13 × (10.0 × 38.6 + 934 × 1.42) + 25 kcal = 1787 calories 0.95 g protein/kg/day = 0.95 g × 38.6 kg = 36.7 grams protein

4. EER = 88.5 – (61.9 × age [y]) + PA × (26.7 × weight [kg] + 903 × height [m]) + 25 kcal EER = 88.5 – (61.9 × 11) + 1.26 × (26.7 × 50.9 + 903 × 1.52) + 25 kcal = 2874 calories 0.95 g protein/kg/day = 0.95 g × 50.9 kg = 48.4 grams protein

5. Energy needs decrease in the child and preadolescent stages because growth decreases. Males have a higher need for calories per kilogram than females do. The percentage of lean body tissue is higher in males, so more kcal are required per pound body weight as compared with females.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 12: Child and preadolescent nutrition

Worksheet 12-1: Case Study—Treatment of Overweight and Obesity in Childhood (LO 12.6)

The Childhood Obesity Action Network released an implementation guide titled “Expert Committee Recommendations on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity” in 2007. The experts who wrote the guide consisted of individuals from the AMA, HRSA, and CDC. The recommendations are available at: http://www.ohsu.edu/xd/health/services/doernbecher/patientsfamilies/healthy-lifestyles/upload/COANImplementationGuide62607FINAL.pdf. You will need these guidelines to complete this case study, as well as growth charts from the CDC, which are available at: http://www.cdc.gov/growthcharts/ Stephanie, 5 years old, has been referred to a registered dietitian because her pediatrician is concerned about her weight gain. Currently she weighs 54 pounds and is 46 inches tall. Questions: 1. What are Stephanie’s current BMI and BMI-for-age percentile? How is her weight classified based on the recommendations?

2. According to these recommendations, what areas should the registered dietitian focus on during the dietary assessment?

3. What stage in the treatment recommendations should be applied to Stephanie’s case, and what does this include?

4. At a 3-month follow-up appointment, Stephanie is 60 lb and 46.5 in. What is Stephanie’s current BMI and BMI-for-age percentile? How is her weight classified with these new recommendations?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 12: Child and preadolescent nutrition

5. What treatment changes are recommended at this point?

6. What are the next stages and recommended treatments?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 12: Child and preadolescent nutrition

Worksheet 12-2: Calculate Energy and Protein Needs for Children and Preadolescents (LO 12.4)

Directions: Use the information from Chapter 10 on page 263 (“Energy Needs”), Chapter 12 on page 306 (“Energy Needs” and “Protein”), and the formulas in the table below to answer the questions.

Table: DRIs for Energy for Children (Available at: http://books.nap.edu/openbook.php?record_id=10490&page=107)

EER for boys ages 3 through 8 years EER = 88.5 − (61.9 × age [y]) + PA × (26.7 × weight [kg] + 903 × height [m]) + 20 kcal

EER for girls 3 ages through 8 years EER = 135.3 − (30.8 × age [y]) + PA × (10.0 × weight [kg] + 934 × height [m]) + 20 kcal

EER for boys ages 9 through 18 Years EER = 88.5 – (61.9 × age [y]) + PA × (26.7 × weight [kg] + 903 × height [m]) + 25 kcal

EER for girls ages 9 through 18 Years EER = 135.3 – (30.8 × age [y]) + PA × (10.0 × weight [kg] + 934 × height [m]) + 25 kcal

1. Calculate the energy and protein requirements for a 4.5-year-old male who weighs 38 pounds, is 39 inches tall, and is considered sedentary.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 12: Child and preadolescent nutrition

2. Calculate the energy and protein requirements for a 5-year-old female who weighs 42 pounds, is 44 inches tall, and is considered active.

3. Calculate the energy and protein requirements for a 10-year-old female who weighs 85 pounds, is 56 inches tall, and is considered low active.

4. Calculate the energy and protein requirements for an 11-year-old male who weighs 112 pounds, is 60 inches tall, and is considered active.

5. What differences do you notice between the children’s energy requirements and the preadolescents’ requirements (i.e., kcal/kg)? What accounts for these differences? [return to top]

ADDITIONAL RESOURCES INTERNET RESOURCES •

General nutrition • Kids Health (Nemours Foundation): http://www.kidshealth.org • Kidnetic (IFIC Foundation): http://www.kidnetic.com • Healthy Eating Index: http://www.usda.gov/cnpp

•

Science of nutrition • Academy of Nutrition and Dietetics (search for “child overweight”): http://www.eatright.org

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 12: Child and preadolescent nutrition

• •

USDA’s Food Patterns for children: https://www.choosemyplate.gov/MyPlatePlan National Academies Press: http://www.nap.edu

•

Child and preadolescent nutrition • Annie E. Casey Foundation: http://www.aecf.org • Centers for Disease Control and Prevention, National Center for Health Services, CDC Growth Charts: http://www.cdc.gov/growthcharts/ • “Supersizing the Pint-Sized: The Need for FDA-Mandated Child-Oriented Food Labeling”: http://digitalcommons.lmu.edu/cgi/viewcontent.cgi?article=2515&context=llr • Action for Healthy Kids: http://www.actionforhealthykids.org/

•

Public food and nutrition programs • School Nutrition Association: https://schoolnutrition.org/ • Bright Futures: http://www.brightfutures.org • Child Nutrition Programs (National School Lunch, School Breakfast, Special Milk, Summer Food Service, and Child and Adult Care Food Programs): http://www.fns.usda.gov/child-nutrition-programs • Fruits and Veggies—More Matters: http://www.fruitsandveggiesmorematters.org • Fruit and Veggie Color Champions: http://www.foodchamps.org • Team Nutrition: http://www.fns.usda.gov/tn/team-nutrition

•

Nationwide priorities and nutritional health • National Center for Complementary and Integrative Health, National Institutes of Health: https://nccih.nih.gov • CDC’s Healthy Youth! Publications and Links: http://www.cdc.gov/HealthyYouth/publications/index.htm • The Center for Health and Health Care in Schools: http://www.healthinschools.org • Model School Wellness Policies: http://www.schoolwellnesspolicies.org/ [return to top]

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 13: Child and preadolescent nutrition: Conditions and interventions

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 13: CHILD AND PREADOLESCENT NUTRITION : CONDITIONS AND INTERVENTIONS

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 3 Chapter Outline ................................................................................................................... 3 Discussion Questions.......................................................................................................... 5 Additional Activities and Assignments .............................................................................. 7 Additional Resources .........................................................................................................12 Internet Resources.................................................................................................................. 12

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to discuss the nutrition needs of children with chronic conditions, such as cystic fibrosis (CF), diabetes mellitus, cerebral palsy (CP), food allergies, phenylketonuria (PKU), and behavioral disorders. Nutrition recommendations for these children are based on children without diseases or conditions, and these can be modified to assist with growth, nutrient requirements, and/or eating abilities.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 13.1

Explain why thinking that children are children first, even if they have conditions that affect their growth and nutritional requirements, suits child developmental milestones.

13.2

Identify the common nutrition problems in children with special healthcare needs and chronic conditions.

13.3

Describe how a growth assessment is modified in children with special healthcare needs.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 13: Child and preadolescent nutrition: Conditions and interventions

13.4

Characterize nutrition recommendations for children who are underweight and overweight, or have difficulties meeting known nutrient requirements.

13.5

Describe the eating and feeding problems of children with special healthcare needs and chronic conditions.

13.6

Compare use of dietary and herbal remedies in children with and without special healthcare needs.

13.7

Explain why children who have special healthcare conditions receive more intensive nutrition services in schools and healthcare settings than other children do.

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KEY TERMS Spinal muscular atrophy (SMA): Condition in which muscle control declines over time as a result of nerve loss, causing death in childhood. Secondary condition: Common consequence of a condition, which may or may not be preventable over time. Scoliosis: Condition in which the vertebral bones in the back show a side-to-side curve, resulting in a shorter stature than expected if the back were straight. Neuromuscular: Term pertaining to the central nervous system’s control of muscle coordination and movement. Juvenile rheumatoid arthritis: Condition in which joints become enlarged and painful as a result of the dysfunction of the immune system; generally, occurs in children or teens. Ketogenic diet: High-fat, low carbohydrate meal plan in which ketones are made from metabolic pathways used in converting fat as a source of energy. Osteoporosis: Condition in which low bone density or weak bone structure leads to an increased risk of bone fracture. Insulin: Hormone usually produced in the pancreas to regulate movement of glucose from the bloodstream into cells within organs and muscles. Postictal state: Time of altered consciousness after a seizure; appears to be like a deep sleep. Athetosis: Uncontrolled movements of the large muscle groups as a result of damage to the central nervous system.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 13: Child and preadolescent nutrition: Conditions and interventions

Neurobehavioral: Pertains to control of behavior by the nervous system. Psychostimulant: Classification of medication that acts on the brain to improve mental or emotional behavior.

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WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • •

• •

Information from the National Survey of Children’s Health, including statistics on children with special health care needs Updated statistics about children in schools with specific learning disabilities, speech and language impairments, autism, developmental delays, and other medical conditions Expanded information on pediatric feeding disorders Updated information on children with attention-deficit/hyperactivity disorder (ADHD)

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CHAPTER OUTLINE I.

Introduction a. “People-first language” is modeled in this chapter dealing with children who have conditions such as cystic fibrosis, diabetes mellitus, cerebral palsy, and behavioral disorders. These are just four of the many chronic conditions that affect nutrition. b. As part of people-first language, the term handicapped is discouraged because of its origin (i.e., using a cap to beg).

II. “Children Are Children First”—What Does that Mean? Explain why thinking that children are children first, even if they have conditions that affect their growth and nutritional requirements, suits child developmental milestones. (LO 13.1) a. The developmental tasks of children are universal, whether or not disabling conditions exist. b. Community support for inclusive treatment and universal design has been mandated (and fostered) by the Individuals with Disabilities Education Act (IDEA). c. General nutrition guidelines are modified to fit children with special needs.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 13: Child and preadolescent nutrition: Conditions and interventions

III. Nutritional Requirements of Children with Special Healthcare Needs Identify the common nutrition problems in children with special healthcare needs and chronic conditions. (LO 13.2) a. Children with special needs “have a wide range of nutritional needs and more variability than other children.” b. Modifications may include lower caloric intake due to small muscle mass, high protein needs due to losses, high fluid intake due to diarrhea or vomiting, and others. IV. Growth Assessment Describe how a growth assessment is modified in children with special healthcare needs. (LO 13.3) a. b. c. d.

The CDC 2000 charts are a good place to begin any child’s growth assessment. Specialized growth charts make accurate monitoring possible (Table 13.1). “Most children with chronic conditions do grow.” Signs needing attention regardless of what growth chart is used are listed on page 331: a weight plateau, a pattern of gain and loss, weight not regained after illness, and unexplained or unintentional weight gain.

V. Nutrition Recommendations Characterize nutrition recommendations for children who are underweight and overweight, or have difficulties meeting known nutrient requirements. (LO 13.4) a. A thorough assessment helps to achieve the goal of maintaining good nutritional status and avoiding exacerbation of the primary condition due to malnutrition. b. Implementing appropriate nutritional approaches requires community support and cooperation between care providers and the family. c. Table 13.2 provides examples of nutritional supplements and formulas for children. d. Vitamin and mineral supplements for children with chronic conditions are discussed. VI. Feeding Disorders in Children with Special Healthcare Needs Describe the eating and feeding problems of children with special healthcare needs and chronic conditions. (LO 13.5) a. This section describes the prevalence, nutritional consequences, and management for cystic fibrosis, diabetes mellitus (prevalence of both type 1 and type 2 are increasing in children), seizures, cerebral palsy, phenylketonuria (PKU), attention-deficit/hyperactivity disorder (ADHD), pediatric HIV, and childhood celiac disease. VII. Nutrition Needs of Children with Specific Disorders

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 13: Child and preadolescent nutrition: Conditions and interventions

a. This section highlights the nutrition problems and interventions for school-age children with several common or unique diagnoses: cystic fibrosis, diabetes mellitus, seizures, cerebral palsy, inborn errors of metabolism, attentiondeficit/hyperactivity disorder, and food allergies. VIII.

Dietary Supplements and Herbal Remedies Compare use of dietary and herbal remedies in children with and without special healthcare needs. (LO 13.6)

a. Families with chronically ill children seek help from many sources, including dietary supplements and herbal therapies. b. Support groups, family, and friend networks pass on anecdotes hoping that something will help. c. To avoid potential harm, several strategies to counter unscientific claims are offered. IX. Sources of Nutrition Services Explain why children who have special healthcare conditions receive more intensive nutrition services in schools and healthcare settings than other children do. (LO 13.7) a. The major agencies overseeing nutrition services for children are the U.S. Department of Agriculture, which administers the Child Nutrition Program, and the U.S. Department of Health and Human Services, which administers the Maternal and Child Health Block Program. b. The IDEA and the 504 Accommodation of the Rehabilitation Act of 1973 require modification of school routines to make them inclusive, meaning all children will have access to education. [return to top]

DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class. 1. Picture yourself as a nutritionist in a pediatric clinic. What does the part of Learning Objective 13.1 that says, “children are children first, even if they have conditions that affect their growth and nutritional requirements,” mean to you? (LO 13.1) 2. “Train a child in the way he should go, and when he is old, he will not depart from it.” Think of one food-related behavior you currently practice that you can trace to your childhood. For example, did you get to prepare boxed macaroni and cheese

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 13: Child and preadolescent nutrition: Conditions and interventions

for your family ... and now you still make it for comfort food? Why did the author use this quotation just before the section on nutritional requirements? (LO 13.1)

3. Children with chronic health problems have more difficulty in reaching the DRI for nutrients. Ask students to come up with reasons why that may be the case. Summarize by showing the bulleted list on p. 331. To take this discussion further: what interventions could deal with each of these reasons? (LO 13.2) 4. Homework: Assign each class member one of the nine conditions in Table 13.1 for which special growth charts are available. Have students explore the growth and development issues in the condition assigned (or chosen); they will need to go outside of the text. (LO 13.3) In class: Discuss the deviations from standard CDC growth charts that make special growth charts useful. What is the most important thing to remember about all these charts? [They allow each child to serve as their own control for tracking growth and development progress.] Does anyone have a successful search strategy to share with the class? (LO 13.3)

5. When a child’s chronic condition is likely to affect height and/or weight status, several signs require further attention. What are these signs? How would you recognize them? Be specific. (LO 13.3)

6. ADHD is a common neurobehavioral condition in children. How common is it? What are the two approaches that have been found most effective in managing ADHD? Describe some approaches that have not been successful. What are the main concerns of parents who have a child with ADHD? Suggest some nutrientdense snacks that would be easy to serve to a child at after-school daycare. How will you deal with the potential food allergies of other children in the daycare program? (LO 13.6)

7. A child with PKU is not allowed to eat meat, eggs, regular dairy products, peanuts, or soybeans in any form. Design a food guidance tool for children with PKU. How would it differ from ChooseMyPlate.gov? (LO 13.6)

8. Seventy percent of children with developmental delays have feeding problems. Generate strategies to deal with one or more of the three given on p. 337. Assume

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 13: Child and preadolescent nutrition: Conditions and interventions

that you are a school principal who is trying to comply with the IDEA regulations: how could you work with families and students who have special needs? (LO 13.5)

9. Explain the causes of cerebral palsy and associated secondary effects. Discuss nutritional interventions to help a child with cerebral palsy attain optimal growth and development. (LO 13.6)

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ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. Type 2 Diabetes Summer Program Design (LO 13.6) Total Time: 40 minutes The incidence of type 2 diabetes is increasing in children, especially in some ethnic groups. Assume the role of a nutritionist who is working with the activity coordinator of a youth center in a Mexican American neighborhood. Your responsibility is to design several sessions of a summer program geared to health promotion and risk reduction. In small groups, outline proposals for three sessions that can be integrated into such a program and provide a rationale for each topic chosen. For instance: overweight is a risk factor for type 2 diabetes. A diet high in unprocessed fruits and vegetables is typically less calorie dense than a diet low in these foods. One session might focus on vegetables as a snack. 2. Protein Needs and Stress (LO 13.2) Total Time: 30 minutes Protein needs increase under physiological stress such as recovery from burns and cystic fibrosis. What are the RDA recommendations for protein for a typical 10-year-old girl? Develop a one-day meal plan that provides adequate calories and 150% of the DRI for protein for her. [See Table 1.6 in Chapter 1.] 3. Counseling for a New Seizure Diagnosis (LO 13.6) Total Time: 25 minutes Seizures are relatively common in children. Pair students and have them role play a counseling session with parents who have a child recently diagnosed with seizures and due to start kindergarten in two months. Be sure to include advice on the postictal state a child may undergo. 4. Complete Worksheet 13-1: Case Study—Living with Type 1 Diabetes (LO 13.6) Total Time: 25 minutes Answer Key:

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 13: Child and preadolescent nutrition: Conditions and interventions

1. Currently Stan is 55th percentile ht/age and 25th percentile wt/age, his BMI = 15.2 kg/m2, and he is 12th percentile BMI for his age. At the time of his diagnosis, Stan was 49th percentile ht/age and 25th percentile wt/age, his BMI = 15.1 kg/m2, and he was 20th percentile BMI for his age. His growth is progressing adequately; need to continue to monitor his weight. 2. Call the party planner and request information about the food that will be served there so he can prepare a plan in advance. 3. According to the ADA Exchange System, a 2-inch piece of cake with frosting is two servings of carbohydrate. Stan could eat a 4-inch piece of cake and stay within his usual carbohydrate intake at snack time. The use of a food model would help Stan picture what a 4-inch piece of cake looks like. 4. If Stan would like to eat other carbohydrate-containing foods at the party, he could increase his dose of insulin—however, it would be best if he plans this out in advance, as this is his first time doing this on his own. He could also eat less cake in order to make room for the other snack items. 5. Complete Worksheet 13-2: Assessment of Nutritional Requirements for Cystic Fibrosis (LO 13.6) Total Time: 30 minutes Answer Key: 1. EER = 135.3 – (30.8  age [y]) + PA  (10.0  weight [kg] + 934  height [m]) + 25 kcal EER = 135.3 – (30.8  10) + 1.13  (10.0  28.2 + 934  1.29) + 25 kcal = 1532 calories  2–4 = 3064–6128 calories 0.95 g protein/kg/day = 0.95 g  28.2 kg = 26.8 grams protein  2–4 = 53.6–107.2 grams protein

2. Assess current nutritional intake and evaluate growth to determine whether intake supports growth. Also, if starting at the low end, monitor the child’s calorie intake and growth to determine whether the recommended level is appropriate to support growth.

3. Answers will vary; examples include: •

Eat whenever you are hungry. This may mean eating several small meals throughout the day.

•

Keep a variety of nutritious snack foods around. Try to snack on something every hour. Try cheese and crackers, muffins, or trail mix.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 13: Child and preadolescent nutrition: Conditions and interventions

•

Make an effort to eat regularly, even if it's only a few bites; or include a nutritional supplement or milkshake.

•

Be flexible. If you aren't hungry at dinnertime, make breakfast, midmorning snacks, and lunch your main meals.

•

Add grated cheese to soups, sauces, casseroles, vegetables, mashed potatoes, rice, noodles, or meat loaf.

•

Use whole milk, half and half, cream, or enriched milk in cooking or beverages.

•

Spread peanut butter on bread products or use it as a dip for raw vegetables and fruit. Add peanut butter to sauces or use it on waffles.

•

Skim milk powder adds protein—try adding two tablespoons of dry skim milk powder in addition to the amount of regular milk in recipes.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 13: Child and preadolescent nutrition: Conditions and interventions

Worksheet 13-1: Case Study—Living with Type 1 Diabetes (LO 13.6) Stan, 11 years old, was diagnosed with type 1 diabetes nine months ago. He is learning how to count carbohydrates for his lunches during the day at school, and his mother helps him with the other meals and snacks he consumes. During the past nine months, Stan has been restricted from eating out with friends because his mother is concerned he won’t be able to count his food intake appropriately, but she recognizes the need to give Stan more independence. He will be attending a birthday party next week and is looking forward to eating birthday cake, although this makes his mother nervous. Stan and his mother have scheduled a visit with a registered dietitian to discuss a plan for the birthday party. He is currently 70 pounds and 57 inches; at the time of his diagnosis, he was 65 pounds and 55 inches. Stan’s usual meal pattern (grams of carbohydrate): Breakfast = 60 grams, lunch = 75 grams, after-school snacks = 60 grams, dinner = 75 grams, bed-time snack = 45 grams. His insulin regimen includes 1 unit Humalog: 15 grams carbohydrate and 20 units of Lantus at bedtime.

Questions: 1. Evaluate Stan’s current growth and BMI compared to those at the time of his diagnosis.

2. How can Stan and his mother best plan for the food that will be served at the birthday party?

3. The party will be at 1 p.m. and the food will be served at 3 p.m.—this is the time Stan usually has his afternoon snack. How much cake with frosting can he consume and stay with his regular dose of insulin?

4. What if Stan wants to have carbohydrate-containing snack foods at the party in addition to the cake?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 13: Child and preadolescent nutrition: Conditions and interventions

Worksheet 13-2: Assessment of Nutritional Requirements for Cystic Fibrosis (LO 13.6) Directions: Using the information from Chapter 13 and the formula provided below, complete this worksheet.

Table: DRIs for Energy for Children (available at: http://books.nap.edu/openbook.php?record_id=10490&page=107)

EER for girls ages 9 through 18 years EER = 135.3 – (30.8  age [y]) + PA  (10.0  weight [kg] + 934  height [m]) + 25 kcal

PA = 1.00 if PAL is estimated to be ≥ 1.0 < 1.4 (sedentary)* PA = 1.13 if PAL is estimated to be ≥ 1.4 < 1.6 (low active) PA = 1.26 if PAL is estimated to be ≥ 1.6 < 1.9 (active) PA = 1.42 if PAL is estimated to be ≥ 1.9 < 2.5 (very active) 1. Calculate the estimated nutritional requirements for a 10-year-old female with cystic fibrosis who weighs 62 pounds, is 51 inches tall, and is considered low active.

2. The estimated calorie requirement for an individual with cystic fibrosis is two to four times the usual recommendation. How would one know the appropriate calorie level to recommend initially?

3. Research nutrition recommendations for cystic fibrosis that can help an individual meet her high calorie and protein requirements (i.e., use the text and reputable websites). What advice could you provide to a patient?

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 13: Child and preadolescent nutrition: Conditions and interventions

ADDITIONAL RESOURCES INTERNET RESOURCES •

Child and preadolescent nutrition: conditions and interventions • Ability Online (support network): http://www.abilityonline.org • American Diabetes Association: http://www.diabetes.org • Cystic Fibrosis Foundation: http://www.cff.org • Exceptional Parent magazine: http://www.eparent.com/ • Ketogenic diet: http://www.epilepsyfoundation.org/aboutepilepsy/treatment/ketogenicdiet/ • National Down Syndrome Society: http://www.ndss.org

•

Public food and nutrition programs • Healthfinder Kids’ Sites: http://healthfinder.gov/FindServices/SearchContext.aspx?topic=14314

•

Nationwide priorities and nutritional health • Statistics—Disability Statistics Center: https://www.disabilitystatistics.org/ • United States—Maternal and Child Health Bureau, Health Resources and Services Administration Programs Overview: http://mchb.hrsa.gov/programs/index.html • U.S. federal government website for disability programs and services: https://www.disability.gov/ [return to top]

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 14: ADOLESCENT NUTRITION

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 2 Chapter Outline ................................................................................................................... 3 Discussion Questions.......................................................................................................... 5 Additional Activities and Assignments .............................................................................. 7 Additional Resources .........................................................................................................15 Internet Resources.................................................................................................................. 15

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to provide an overview of normal biological and psychosocial growth and development among adolescents and how these experiences affect the nutrient needs and eating behaviors of teens. The tasks of adolescence include the development of a personal identity and a unique value system separate from parents and other family members; a struggle for personal independence accompanied by the need for economic and emotional family support; and adjustment to a new body that has changed in shape, size, and physiological capacity. Common concerns related to adolescent nutrition and effective methods for educating and counseling teens are also discussed.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 14.1

Explain why sexual maturity and biological maturity (biological age) are better determinants of nutritional needs than chronological age.

14.2

Explain how the psychosocial developmental stages of adolescence, including levels of abstract reasoning and critical thinking abilities, affect the types of

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

health education messages and intervention components that are effective with teens. 14.3

Describe at least three eating behaviors commonly seen among adolescents and the potential consequences of these behaviors on nutrition status.

14.4

Compare which food groups and nutrients adolescents consume in lower than recommended amounts and which food groups and nutrients they consume in higher-than-recommended amounts, and how these behaviors may impact overall health status.

14.5

Identify the key components of nutrition assessment and screening of adolescents and how resulting data can be used during nutrition education and counseling.

14.6

Describe the roles that peers, families, schools, and communities play in determining the dietary behaviors and nutritional status of adolescents.

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KEY TERMS Secondary sexual characteristics: Physiological changes that signal puberty, including enlargement of the testes, penis, and breasts and the development of pubic and facial hair. Menses: The process of menstruation. Menarche: The occurrence of the first menstrual cycle. Fasting: Going 24 hours or more without eating. Serum iron, plasma ferritin, and transferrin saturation: Measures of iron status obtained from blood plasma or serum samples.

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WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • •

Updated to reflect the Dietary Guidelines for Americans 2020–2025 Updated information related to frequency of consuming meals and snacks Updated information regarding current intake of food groups

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

• • •

Updated information on school meals program regulations and best practices Modified illustrations and tables Updated DRI for energy during adolescence

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CHAPTER OUTLINE I.

Introduction a. Adolescence generally refers to the period between ages 11 and 21. b. Physical, cognitive, and psychosocial maturation occur during these years, but not at the same speed for everyone. c. Figure 14.1 shows the different developmental paths of females and males.

II. Normal Physical Growth and Development Explain why sexual maturity and biological maturity (biological age) are better determinants of nutritional needs than chronological age. (LO 14.1) a. Development, as seen by sexual maturation, is a better indicator of nutritional needs than chronological age is. b. While the sequence of the biological events occurring during puberty is consistent, their onset, duration, and tempo are not. c. Therefore, a five-stage Sexual Maturation Rating (SMR) is preferable to age when indicating growth, development, and associated health needs. d. Table 14.1 profiles the sexual maturity rating for girls and boys. Figures 14.2 and 14.3 show the sequence of physiological change for females and for males. e. Peak weight gains and skeletal mass gains increase the need for nutrients and appetite. Changes in body composition lead to changes in reproductive status. III. Psychosocial and Cognitive Development Explain how the psychosocial developmental stages of adolescence, including levels of abstract reasoning and critical thinking abilities, affect the types of health education messages and intervention components that are effective with teens. (LO 14.2) a. Early adolescence is characterized by concrete thinking, egocentrism, and impulsive behavior. b. The development of emotional and social independence from the family marks middle adolescence. c. Abstract reasoning skills (begun during mid-adolescence), personal identity, and personal choice as well as individual moral beliefs are developed during late adolescence. IV. Health- and Nutrition-Related Behaviors During Adolescence

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

Describe at least three eating behaviors commonly seen among adolescents and the potential consequences of these behaviors on nutrition status. (LO 14.3) a. Because eating habits of adolescents change, it is suggested that assessments ask about current behaviors and intake. b. A model depicting how the environment, personal factors, and societal structure (macro-systems) affect current nutrition behaviors is shown in Figure 14.4. c. Health and nutrition surveys report on specific nutrition behaviors. For instance, snacking accounts for about 25% of daily energy intake. d. Soft drinks are popular snacks. High soft drink consumption that displaces the consumption of calcium-rich beverages may prevent achievement of optimal bone density. e. Meal skipping is relatively common, and “only 27 percent of high school students eat breakfast on a daily basis.” f. Vegetarianism, which seems very popular, is practiced by only 5% of the adolescent population. g. Table 14.2 shows types of vegetarian diets and excluded foods. h. The advantages of a vegetarian diet are discussed in this section. i. Individual, social, and environmental factors affect physical activity (distinguished from exercise) in teens. j. Generally speaking, males are more active than females. V. Dietary Requirements, Intake, and Adequacy Among Adolescents Compare which food groups and nutrients adolescents consume in lower than recommended amounts and which food groups and nutrients they consume in higher-than-recommended amounts, and how these behaviors may impact overall health status. (LO 14.4) a. Table 14.4 shows DRI levels for adolescents. b. Adequate energy supports linear growth and sexual maturation. c. Caloric and protein recommendations are made relative to nutritional needs to support growth (see Table 14.5), which is different than the basis for infants, for whom calorie and protein recommendations are made per kilogram (based on chronological age). d. Among the nutrients highlighted in this section are carbohydrate, fiber, fat, calcium, iron, vitamin D, and folate. e. A description of dietary intake and adequacy among adolescents ends the section: “most adolescents do not consume diets that comply with MyPlate or the Dietary Guidelines for Americans.” VI. Nutrition Screening, Assessment, and Intervention

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

Identify the key components of nutrition assessment and screening of adolescents and how resulting data can be used during nutrition education and counseling. (LO 14.5) a. Recommendations for assessing and screening nutrition behaviors to promote overall health for young adolescents (ages 12–17) and older adolescents (ages 18–21) are offered in Table 14.7. b. A comparison of dietary assessment tools is presented in Table 14.9. c. Indicators of nutritional risk and their relevance for nutrition are thoroughly outlined in Table 14.10. This table also links risk indicators with criteria for further screening and assessment. d. Suggestions for nutrition education and counseling complete this section. VII. Promoting Healthy Eating and Physical Activity Behaviors Describe the roles that peers, families, schools, and communities play in determining the dietary behaviors and nutritional status of adolescents. (LO 14.6) a. Effective messages are targeted to youths, and nutrition education activities engage teens so that they can develop food-related skills. b. Parents are involved because they purchase groceries and plan household meals. Teens “tend to eat what is available and convenient.” c. Schools (including the National School Lunch Program) and other community programs influence how adolescents learn about nutrition and how they put their beliefs and values into practice. d. School wellness policies are discussed, and recommendations for school health programs are provided in Table 14.11. e. Community-based programs are also explored, including Urban Roots, which offers multiple youth programs. [return to top]

DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class. 1. The chapter’s author, Jamie Stang, suggests these review questions as a great place to start exploring the content of Chapter 14. (LO 14.1) •

What is biological age, and why should it be used instead of chronological age to determine adolescent nutrient needs?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

•

Why don’t adolescent BMI charts use a single cutoff point for determining obesity in the same way adult BMI charts do?

2. The Academy of Nutrition and Dietetics has published and posted a Pediatric Weight Management Guideline to the Evidence Analysis Library (EAL). The guideline contains systematically developed recommendations, based on scientific evidence, to assist practitioners providing care for children and adolescents who are overweight and obese. Recommendations include: • Treatment considerations such as setting weight goals, group and individual treatment, family participation, nutrition counseling, and behavior therapy strategies • Interventions involving energy restriction, reduced glycemic load, very low carbohydrate, protein sparing modified fast, and physical activity Although this EAL Guideline does not include the AMA’s recently updated recommendations for pediatric overweight (particularly the new definitions), it is a very comprehensive, thorough, and evidenced-based guideline for practitioners. Access to this guideline is open to the public at Topic: Pediatric Weight Management - EAL Portal (andeal.org). Review the introduction and the guidelines. Lead a class discussion on the importance of evidence-based practice guidelines. (LO 14.6) 3. Teens are concerned about appearance, weight, and having a lot of energy. Propose some motivational messages that would promote foods currently lacking in the diets of teen girls and boys. Suggest several dietary behaviors to combat low calcium intake or low iron status in either males or females. (LO 14.2) 4. Describe the meal-skipping behaviors of the teenage population. Do you think meal skipping, as done by the average teen, is a problem? If your brother or sister were preparing to take college entrance exams, what sort of dietary advice could you give them? [For example, “Eating breakfast can enhance cognitive performance.”] (LO 14.3)

5. “As much as 50 percent of ideal adult body weight is gained during adolescence.” What are the implications of this statement for the nutritional health of a young male or female? If you were the parent of a preadolescent daughter who was worried about “being fat,” how might you prepare her for the coming weight gain (and perhaps the accretion of body fat)? (LO 14.1)

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. Marketing Assignment (LO 14.1) Total Time: Will vary Have each student develop a marketing brochure that would be distributed in pediatricians’ offices. Review Figure 14.2 (females) and Figure 14.3 (males), which show the sequence of physiological changes during puberty. In a class overview, identify the nutritional implications of changes occurring during adolescence for a male or a female (pick one). Then have students develop a guide to help parents prepare for feeding adolescents during their growth spurt. The brochure should include expected changes in calorie and protein needs and teach parents about what a gain of 18 to 20 pounds in one year means in added calories per day. The goal of marketing is to put yourself in the customer’s view (i.e., put yourself in the parent’s shoes). What would a parent want to know about their son’s or daughter’s growth spurt?

2. Essential Fatty Acids (LO 14.4) Total Time: 25 minutes Distribute the table below, which lists plant sources of alpha-linolenic and linoleic acid. Have students calculate the linoleic acid to alpha-linolenic acid ratio. [Walnuts = 2.8:1, walnut oil = 5.1:1, canola oil = 2:1, soybean oil = 7.8:1, soybeans = 7.8:1, tofu = 7.3:1] Have students locate recipes or brainstorm how they would incorporate these foods into their diets. If students need a review of the chemical structure, a nice picture graphic can be downloaded and printed from http://curezone.com/foods/fatspercent.asp

Food Source

Linoleic acid (g)

Alpha-Linolenic Acid (g)

18:2n-6

18:3n-3

Walnuts, 2 Tbsp (1 oz)

5.4

1.9

Walnut Oil, 1 Tbsp

7.6

1.5

Canola Oil, 1 Tbsp

3.2

1.6

Soybean Oil, 1 Tbsp

7.0

0.9

Soybeans, ½ cup cooked

3.9

0.5

Tofu, ½ cup

2.9

0.4

3. Fast Food and Teens (LO 14.3) Total Time: 30 minutes

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

Teens like to eat at fast-food restaurants and food courts for a number of reasons. Divide the class into small groups and have each group design a teenfriendly restaurant concept that would support the nutrient concerns of growing adolescents. What would be on the menu? Do you think it is possible to get teens to eat more fruits and vegetables? What are potential strategies to increase fruit and vegetable consumption in teens? How would you promote your new place? Would you stress that it served health-promoting foods?

4. Complete Worksheet 14-1: Case Study—Nutrition Education and Counseling for Adolescent Obesity (LO 14.6) Total Time: 25 minutes Answer Key: 1. 28 kg/m2. This classifies him as obese according to the June 2007 American Medical Association recommendations for treating childhood obesity. 2. Answers will vary but may include increase the consumption of fruits and vegetables, encourage nonfat dairy and adequate calcium intake, provide alternatives to fast-food meals and fried foods, provide nutrition education regarding food sources of fat, assess current level of physical activity, and encourage family meals. 3. Treat adolescents as individuals, establish rapport, encourage the involvement of the adolescent in the decision-making process, limit goals to one to two per session. 4. Answers will vary and may include adolescents who eat dinner with their families are less likely to have eating disorders and use drugs, tend to have greater psychosocial well-being, and use fewer unhealthy weight management practices.

5. Complete Worksheet 14-2: Assessment of the Nutritional Needs of an Adolescent Male (LO 14.4) Total Time: 30 minutes Answer Key: 1. Serving Size

Calories

Fat (g)

Calcium (mg)

Cheerios

2 cups

221

2.54

243

20.64

2% milk

1 cup

122

4.8

285

0.07

Orange juice

1 cup

112

0.15

0.25

Food or Beverage Item

Iron (mg)

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

Serving Size

Calories

Fat (g)

Calcium (mg)

205

5.3

13.5

3.63

Cheeseburger w/ mayo on a bun

347

164

2.81

French fries

182

0.083

Food or Beverage Item Pop-Tart

Iron (mg)

Cola

16 ounces

184

0.1

0.55

Whole-wheat bread

2 slices

138

2.35

1.85

Peanut butter

6 Tbsp

371

32.3

1.2

Jelly

2 Tbsp

101

0.01

0.07

2% milk

1 cup

122

4.8

285

0.07

Spaghetti, cooked

2 cups

440

2.58

3.7

Spaghetti sauce w/ meat

1 cup

281

4.13

Garlic toast

2 med. slices

189

7.3

1.27

Mixed salad greens

1 cup

0.64

French dressing

¼ cup

286

0.5

Ice cream

1 cup

267

14.6

170

0.12

Potato chips

1 cup

175

0.52

Daily Totals:

3752

161

1294

42.1

2. EER = 88.5 – (61.9 × age [y]) + PA × (26.7 × weight [kg] + 903 × height [m]) + 25 kcal EER = 88.5 – (61.9 × 13) + 1.26 × (26.7 × 52.3 + 903 × 1.6) + 25 kcal = 2889 calories

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

0.85 g protein/kg/day = 0.85 g × 52.3 kg = 44.5 grams protein

3. 161 grams of fat × 9 kcal/gram of fat = 1449 calories  3752 total calories = 38.6%

4. Calcium RDA = 1300 mg—he is very close to meeting his calcium intake. Iron RDA = 8 mg—his intake is exceeding his dietary needs.

5. Answers will vary. Nutrition education regarding portion sizes, increasing fruit and vegetable consumption, looking for ways to decrease saturated fat intake (e.g., switching to nonfat milk, replacing hamburger with grilled skinless chicken, meatless spaghetti sauce, baked potato chips, low-fat salad dressing), diet soda, lower juice consumption, and whole-grain toast instead of Pop-Tarts at breakfast.

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

Worksheet 14-1: Case Study—Nutrition Education and Counseling for Adolescent Obesity (LO 14.6) EJ is a 14-year-old male who currently resides at a behavioral health residential treatment facility. He has been diagnosed with obesity and hyperlipidemia, most likely due to side effects from the medications he is taking for bipolar disorder. The registered dietitian has been asked to speak with EJ about his new diet order for a low-fat diet and to provide suggestions to EJ’s family. EJ is expected to return home next month. His family has been participating in family counseling weekly with EJ while he has been at the facility. EJ is currently 195 pounds and 70 inches tall. EJ’s mother reports that EJ typically eats at fast-food restaurants after school three or four days a week. His intake of fruits and vegetables has only been 1–2 daily while at the facility, and his mother indicates this is more than he eats at home. When EJ does drink milk, it’s usually whole milk. EJ’s family is very busy, and often EJ and his two older siblings prepare their own dinner.

Questions: 1. What is EJ’s BMI? How does this classify his weight at this time?

2. What dietary recommendations do you have, specific to EJ’s situation, that can help him improve his nutritional intake and reduce his fat consumption?

3. What guidelines do you need to keep in mind as you provide nutrition education and counseling to adolescents?

4. Use PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) to research the impact of family meals in the lives of adolescents. What is the consensus on family meals as they relate to the health of adolescents?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

Worksheet 14-2: Assessment of the Nutritional Needs of an Adolescent Male (LO 14.4) Directions: Using the information in Tables 14.4 and 14.5, the formula provided below, the information on “Energy and Nutrient Requirements of Adolescents” (pp. 358– 363), and the “What’s in the Foods You Eat” search tool (www.ars.usda.gov/foodsearch), complete this worksheet.

Table: DRIs for Energy for Adolescents (available at: http://books.nap.edu/openbook.php?record_id=10490&page=107)

EER for boys ages 9 through 18 years EER = 88.5 − (61.9 × age [y]) + PA × (26.7 × weight [kg] + 903 × height [m]) + 25 kcal

PA = 1.00 if PAL is estimated to be ≥ 1.0 < 1.4 (sedentary) PA = 1.13 if PAL is estimated to be ≥ 1.4 < 1.6 (low active) PA = 1.26 if PAL is estimated to be ≥ 1.6 < 1.9 (active) PA = 1.42 if PAL is estimated to be ≥ 1.9 < 2.5 (very active)

1. Listed below is the 24-hour recall for a 13-year-old male. Using the “What’s in the Foods You Eat” search tool, complete this table. Food or Beverage Item

Serving Size

Cheerios

2 cups

2% milk

1 cup

Orange juice

1 cup

Pop-Tart

Calories

Fat (g)

Calcium (mg)

Iron (mg)

Cheeseburger w/ mayo on a bun French fries

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

Food or Beverage Item

Serving Size

Cola

16 ounces

Whole-wheat bread

2 slices

Peanut butter

6 Tbsp

Jelly

2 Tbsp

2% milk

1 cup

Spaghetti, cooked

2 cups

Spaghetti sauce w/ meat

1 cup

Garlic toast

2 med. slices

Mixed salad greens

1 cup

French dressing

¼ cup

Ice cream

1 cup

Potato chips

1 cup

Calories

Fat (g)

Calcium (mg)

Iron (mg)

Daily Totals:

2. Calculate the energy and protein requirements for a 13-year-old male who weighs 115 pounds, is 63 inches tall, and is considered active.

3. What percentage of his total calorie intake is provided by fat?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

4. How do his intakes of calcium and iron compare with the DRI for his gender and age (Table 14.4 and inside front cover)?

5. What suggestions do you have for improving his nutritional intake?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

ADDITIONAL RESOURCES INTERNET RESOURCES •

General nutrition •

Oldways Preservation Trust (provides four additional cultural and ethnic food guide pyramids): http://oldwayspt.org/

• •

•

Vegetarian Resource Group: http://www.vrg.org

Science of nutrition •

Academy of Nutrition and Dietetics: http://www.eatright.org

•

American Heart Association: http://www.heart.org

•

National Cancer Institute: http://www.cancer.gov/

Adolescent nutrition •

American Medical Association (Promoting Adolescent Health): https://www.ama-assn.org/delivering-care/population-care/whatphysicians-can-do-promote-teen-health

•

Bright Futures: http://www.brightfutures.org

•

Urban Roots Youth Programs: http://urbanrootsmn.org/programs/

•

American Academy of Pediatrics on “The Crucial Role of Recess in School”: http://pediatrics.aappublications.org/content/131/1/183

• •

President’s Council on Fitness, Sports & Nutrition: http://www.fitness.gov/

Public food and nutrition programs •

U.S. Department of Agriculture National Agricultural Library: http://fnic.nal.usda.gov/

•

School Nutrition Association: https://schoolnutrition.org/

•

Model School Wellness Policies (National Alliance for Nutrition and Activity): http://www.schoolwellnesspolicies.org

•

Team Nutrition: http://www.fns.usda.gov/team-nutrition

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 14: Adolescent Nutrition

•

Nationwide priorities and nutritional health •

United States •

Centers for Disease Control and Prevention, Division of Nutrition, Physical Activity, and Obesity: http://www.cdc.gov/nccdphp/dnpao/index.html

•

Centers for Disease Control and Prevention (Morbidity and Mortality Weekly Report): http://www.cdc.gov/mmwr

•

Environmental Protection Agency (Ground Water and Drinking Water): http://water.epa.gov/drink/index.cfm

•

Food and Drug Administration: http://www.fda.gov

•

National Center for Complementary and Alternative Medicine, National Institutes of Health: http://nccam.nih.gov/

•

National Center for Education in Maternal and Child Health: http://www.ncemch.org

•

U.S. Department of Agriculture, Center for Nutrition Policy and Promotion: http://www.cnpp.usda.gov/

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 15: Adolescent Nutrition: Conditions and Interventions

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 15: ADOLESCENT NUTRITION : CONDITIONS AND INTERVENTIONS

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 2 Chapter Outline ................................................................................................................... 2 Discussion Questions.......................................................................................................... 4 Additional Activities and Assignments .............................................................................. 6 Additional Resources .........................................................................................................13 Internet Resources.................................................................................................................. 13

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to discuss specific nutrition concerns that affect significant numbers of adolescents, including overweight, participation in competitive sports, substance abuse, eating disorders, hypertension, and hyperlipidemia.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 15.1

Describe at least five chronic health issues that are considered comorbid conditions of adolescent obesity, including the proposed mechanisms by which obesity raises the risk for these conditions.

15.2

Understand the prevalence and patterns of supplement use among adolescents, including nutritive, non-nutritive, and performance enhancing supplement use.

15.3

Determine the unique energy, protein, and micronutrient needs of competitive adolescent athletes who have not yet completed growth and development.

15.4

Compare and contrast national dietary recommendations to prevent and treat hypertension and hyperlipidemia in adolescents.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 15: Adolescent Nutrition: Conditions and Interventions

15.5

Differentiate between disordered eating behaviors and eating disorders based on frequency and severity of symptoms and anticipated outcomes.

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KEY TERMS Anorexia nervosa (AN): An eating disorder characterized by refusal to maintain body weight at or above a minimally normal weight for age and height. Individuals have an intense fear of gaining weight or becoming fat, even though they are underweight. Bulimia nervosa (BN): An eating disorder characterized by the consumption of large amounts of food with subsequent purging by self-induced vomiting, laxative or diuretic abuse, enemas, and/or obsessive exercising. Binge-eating disorder (BED): An eating disorder characterized by periodic binge eating, which normally is not followed by purging. People must experience eating binges twice a week on average for over 6 months to qualify for this diagnosis.

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WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • • •

Updated information on prevalence and treatment of overweight and obesity among teens Updated information on disordered eating and eating disorders among teens Updated content related to screening and intervention for chronic health conditions Modified illustrations and tables

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CHAPTER OUTLINE I.

Introduction a. Adolescent nutrition topics presented in Chapter 15 are those affecting the nutritional status of significant numbers of teens.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 15: Adolescent Nutrition: Conditions and Interventions

b. The topics include overweight and obesity; nutrition for adolescent athletes; substance abuse among adolescents; special dietary concerns among adolescents; and dieting, disordered eating, and eating disorders. II. Overweight and Obesity Describe at least five chronic health issues that are considered comorbid conditions of adolescent obesity, including the proposed mechanisms by which obesity raises the risk for these conditions. (LO 15.1) a. Weight status is determined by comparing BMI to age-specific standards (percentiles), in contrast to overweight/obesity classification for adults. b. BMI growth curves for teen females and males can be found at http://www.cdc.gov/growthcharts/, and Figure 15.1 shows an example of weight for age. c. Overweight teens are at risk for chronic conditions such as diabetes, hypertension, and dyslipidemia. d. Figure 15.2 shows primary care assessments based on adolescent BMI. e. Table 15.1 describes calculation and interpretation of BMI for pediatric populations, pages 378–380 provide an overview of staged treatment based on BMI status, and Table 15.2 reviews guidelines for the consideration of bariatric surgery in adolescents. III. Dieting, Disordered Eating, and Eating Disorders Differentiate between disordered eating behaviors and eating disorders based on frequency and severity of symptoms and anticipated outcomes. (LO 15.5) a. A depiction of a continuum of eating concerns and disorders (Figure 15.3) helps students get an overview of this complex topic. b. Since over half of teen girls are dieting, this continuum offers a personally relevant structure for many students. c. The structure also aids classification of dieting behaviors and sets the stage for life-long learning about weight management. d. A series of tables (Tables 15.5 through 15.9) in this section supports the diagnosis and thorough treatment of eating disorders. IV. Nutrition for Adolescent Athletes Determine the unique energy, protein, and micronutrient needs of competitive adolescent athletes who have not yet completed growth and development. (LO 15.3) a. Temperature regulation mechanisms are not yet mature; therefore, young teens are vulnerable to heat illnesses. b. The use of fluids and special dietary practices (carbohydrate-loading regimens and high-protein diets) are discussed.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 15: Adolescent Nutrition: Conditions and Interventions

V. Special Dietary Concerns Among Adolescents Compare and contrast national dietary recommendations to prevent and treat hypertension and hyperlipidemia in adolescents. (LO 15.4) a. Substance abuse: Four percent of adolescents smoke at least one cigarette a day. b. According to data from the YRBS, 35% of adolescents consume alcohol. c. Alcohol consumption displaces important nutrients in the diet. d. Illicit drug use is reported by 23% of adolescents. e. Table 15.6 summarizes how substance use can impact nutritional status. f. Iron-deficiency anemia: Wide-ranging effects of the most common nutritional deficiency among teens include fatigue, impaired growth, and depressed immune system. g. Table 15.7 provides the Centers for Disease Control and Prevention age- and gender-based criteria for determining anemia. Iron-rich foods (Chapter 1) and supplements are recommended as treatment. h. Hypertension: Table 15.14 lists the criteria for detecting and diagnosing hypertension. i. A family history of hypertension, overweight, and a sedentary lifestyle are among the risk factors for developing hypertension. j. Hyperlipidemia: Many adolescents have high blood cholesterol levels. k. Many of the risk factors for developing hyperlipidemia overlap with the risk factors for developing hypertension. l. Diabetes and metabolic syndrome: Type 1 diabetes accounts for most of the cases of diabetes in people younger than age 20 years. m. Type 2 diabetes typically occurs in adolescents who are obese and have a strong family history of the disease. n. Studies suggest that 2–9% of teens have metabolic syndrome; however, teens are often not assessed for this. o. Children and adolescents with chronic health conditions: A significant portion of the adolescent population (about 18%) suffers from chronic health conditions such as delayed growth or inborn errors of metabolism. p. The treatment of these conditions ordinarily requires individualized care by a medical team.

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DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 15: Adolescent Nutrition: Conditions and Interventions

1. The text states that “Dieting behaviors among adolescents, and in particular adolescent girls, tend to be alarmingly high.” Approximately 63% of adolescent females and 33% of adolescent males are attempting weight loss. How are overweight and obesity defined in adolescents? What is the prevalence of overweight/obesity among adolescents? Is it different among females and males? What are the nutritional implications of attempted weight loss in a growing individual? (LO 15.1) 2. The emphasis on decreasing dietary fat can lead people to choose sugar instead. Discuss the relative merits of the following snacks for teens: mixed nuts vs. soda, sherbet/sorbet vs. ice cream, pretzels vs. popcorn, 2% unflavored milk vs. chocolate skim milk, and other comparisons students might voice. How are each of these foods classified based on the MyPlate categories? (LO 15.1) 3. Compare the diagnostic criteria for two types of eating disorders: anorexia nervosa (Table 15.5) and bulimia nervosa (Table 15.6). (LO 15.2) 4. Young teen athletes have not yet developed mature temperature regulation mechanisms and are vulnerable to heat illnesses. How is heat illness identified? Suggest nutritional strategies that can help to prevent and to treat heat illnesses. (LO 15.3) 5. Nutritional status is linked to substance use. Is our country doing enough to control alcohol use by adolescents? Provide an example of an alcohol-related message that would get and keep your attention. Does it promote drinking? What do you think of the warning labels on alcohol? (LO 15.4) 6. Adolescents’ reasons for taking nutritional supplements include building muscle and losing weight. Thinking back about your own adolescence—how did the desire to build muscle and lose weight affect your own nutritional habits? (LO 15.3) 7. Which specific nutrients enhance muscle development? Which enhance weight loss? [This could be considered a “trick question” because exercise and the energy nutrients contribute to muscle building; vitamins and minerals act as catalysts in metabolism; and stimulants and nicotine, as well as exercise, increase metabolic rates, which can aid weight loss.] (LO 15.3) 8. Name the basic risk factors for hypertension. Why is hypertension an important topic in a chapter on adolescent nutrition? Knowing what you know about adolescent food habits, suggest some hypertension-appropriate snacks that could be taken in a backpack and eaten on the way to school. (LO 15.4)

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 15: Adolescent Nutrition: Conditions and Interventions

ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. Heart Disease and Teens (LO 15.4) Total Time: 20 minutes Go to the website of the American Heart Association (www.heart.org) and explore nutritional information that applies to individuals under 21 years of age. Considering the fact that one in four teens has elevated blood cholesterol levels, find an example of food-based nutritional guidance (on this or related sites) that you think teens would find relevant and might adopt. Be prepared to tell the class about your search strategies.

2. The “Thin Commandments” (LO 15.2) Total Time: 40 minutes A recovering health professional, Carolyn Costin, has formulated rules related to messages girls develop about their weight that she calls the “Thin Commandments.” She is an expert in the treatment of eating disorders. She has also written two books (The Eating Disorder Sourcebook [Lowell House] and Your Dieting Daughter [Brunner/Mazel]) on the subject and supervises inpatient and outpatient treatment of eating disorders. You may visit her website at http://www.montenido.com This is one way to begin talking about eating disorders. Divide the class into 10 subgroups and have them identify ways to talk about these false commandments. Use the information on prevention and treatment of eating disorders from the text to confront the meaning behind the “Thin Commandments.” The Thin Commandments 1. If you aren't thin you aren't attractive. 2. Being thin is more important than being healthy. 3. You must buy clothes, cut your hair, take laxatives, starve yourself, do anything to make yourself look thinner. 4. Thou shall not eat without feeling guilty. 5. Thou shall not eat fattening food without punishing oneself afterwards. 6. Thou shall count calories and restrict intake accordingly. 7. What the scale says is the most important thing. 8. Losing weight is good/gaining weight is bad. 9. You can never be too thin. 10. Being thin and not eating are signs of true will power and success.

3. Complete Worksheet 15-1: Case Study—Nutrition Intervention for Anorexia Nervosa (LO 15.2) Total Time: 25 minutes Answer Key:

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 15: Adolescent Nutrition: Conditions and Interventions

1. See below for Kelly’s growth chart data. Kelly has failed to gain weight during a period of growth. Her weight and height are below average for her age and are currently at a critical low point. Dat Weight e 12th birthda y

13th birthda y

13 years, 6 month s

14 years

l b

Weight for Age %

Height for Age %

Height

15th percenti le

<5th percenti le

i n . i n . i n .

i n .

BMI

BMI for Age %

10th 16.1 percenti kg/m 2 le

20th percenti le

9th 16.7 percenti kg/m 2 le

20th percenti le

8th 16.2 percenti kg/m 2 le

12th percenti le

5th 15.3 percenti kg/m 2 le

<5th percenti le

2. See the above growth data; amenorrhea for the past six months, and intense anxiety/fear of weight gain. 3. According to the 2011 Academy of Nutrition and Dietetics position statement, “A multidisciplinary team, including nutrition, medical, and mental health professionals, provides the comprehensive treatment needed.” While RDs who work with these patients have typically received advanced training in this area and are an important part of the team, they are not able to provide the range of treatments (which may include drugs and psychotherapy, for example) needed to effectively address anorexia nervosa. 4. Normalizing her food intake.

4. Complete Worksheet 15-2: Calculating the Nutritional Requirements in Anorexia Nervosa (LO 15.2) Total Time: 30 minutes Answer Key:

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 15: Adolescent Nutrition: Conditions and Interventions

1. EER = 135.3 – (30.8  age [y]) + PA  (10.0  weight [kg] + 934  height [m]) + 25 kcal EER = 135.3 – (30.8  14) + 1.0  (10.0  34.5 + 934  1.5) + 25 kcal = 1475 calories 0.85 g protein/kg/day = 0.85 g  34.5 kg = 29.3 grams protein

2. 1475 calories  34.5 kilograms = 42.7 calories per kilogram 3. 1035 to 1200 calories 4. Answers will vary but might include: Starches

Lean Meats

Vegetables

Fruits

Low-Fat (1%) Milk

Fats

Breakfast

Lunch

Snack 1

Dinner

Snack 2

Total

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 15: Adolescent Nutrition: Conditions and Interventions

Worksheet 15-1: Case Study—Nutrition Intervention for Anorexia Nervosa (LO 15.2) Kelly, a 14-year-old female, has been referred to a registered dietitian as part of her treatment plan for a new diagnosis of anorexia. Members of Kelly’s treatment team include her primary care physician, a psychiatrist, her school health nurse, her parents, and a registered dietitian. Kelly started to display an intense anxiety of gaining weight when her parents divorced (she was 12 ½ years old at the time). Her growth data is provided below. Kelly started menses when she was 12, but hasn’t had a period for the past year. Her usual food intake in the past three months includes 4 diet Cokes, 15 raw baby carrots, and 1 slice of diet bread per day (approximately 100 calories per day). Weight for Age %

Date

Weight

Height

12th birthday

72 lb

56 in.

13th birthday

80 lb

58 in.

13 years, 6 months

80 lb

59 in.

14 years

76 lb

59 in.

Height for Age %

BMI

BMI for Age %

Questions: 1. Complete the above table with data from growth charts (see http://www.cdc.gov/growthcharts/ for sample growth charts). Using the completed growth chart data, what patterns do you see in Kelly’s growth over the past two years?

2. Based on the information in this case study, what evidence led to the diagnosis of anorexia in Kelly?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 15: Adolescent Nutrition: Conditions and Interventions

3. Review the causes of disordered eating and eating disorders and the goals of eating disorder treatment programs on pages 394–395. Why is it important that Kelly is being seen by an entire treatment team versus only a registered dietitian?

4. Where should the registered dietitian start with Kelly’s nutrition care plan?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 15: Adolescent Nutrition: Conditions and Interventions

Worksheet 15-2: Calculating the Nutritional Requirements in Anorexia Nervosa (LO 15.2) Directions: Using the information provided below, complete the worksheet. Kelly, a 14-year-old female, has been referred to a registered dietitian as part of her treatment plan for a new diagnosis of anorexia nervosa. She is currently 76 lb and 59 in. Her food intake has consisted of approximately 100 calories per day over the past three months. She has been banned from all unnecessary physical activity at this time. Table 1: DRIs for Energy for Adolescents (Available at: http://books.nap.edu/openbook.php?record_id=10490&page=107) EER for girls ages 9 through 18 years EER = 135.3 – (30.8  age [y]) + PA  (10.0  weight [kg] + 934  height [m]) + 25 kcal PA = 1.00 if PAL is estimated to be ≥ 1.0 < 1.4 (sedentary) PA = 1.13 if PAL is estimated to be ≥ 1.4 < 1.6 (low active) PA = 1.26 if PAL is estimated to be ≥ 1.6 < 1.9 (active) PA = 1.42 if PAL is estimated to be ≥ 1.9 < 2.5 (very active)

Table 2: Refeeding and Normalization of Weight in Anorexia Nervosa Source: King K, Klawitter B. Nutrition Therapy Advanced Counseling Skills. 3rd edition. Philadelphia, PA: Wolters, Kluwer, Lipincott, Williams & Wilkins; 2007. Initial Phase •

30 calories per kilogram

•

No less than 1200 calories

Weight Gain •

Intensive program: increase 250–300 calories every 3–7 days until goal weight is achieved; should gain 2–3 pounds per week

•

Outpatient: 500–1000 calories/week; should gain 1–2 pounds per week

Maintenance •

30–34 calories per kilogram plus additional calories for activity

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 15: Adolescent Nutrition: Conditions and Interventions

1. Use the DRIs to estimate the calorie and protein needs for Kelly at her current weight.

2. How many calories per kilogram would the DRIs provide?

3. Using the guidelines in Table 2, how many calories per day should be a goal for Kelly?

4. Using the American Dietetic Association Exchanges, create a meal plan for Kelly to use as a guide in meeting this daily calorie requirement.

Starches

Lean Meats

Vegetables

Fruits

Low-Fat (1%) Milk

Fats

Breakfast Lunch Snack 1 Dinner Snack 2 Total

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 15: Adolescent Nutrition: Conditions and Interventions

ADDITIONAL RESOURCES INTERNET RESOURCES •

General nutrition • American Heart Association (nutrition tips and virtual cookbook for heart health): https://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/HealthyEating_UCM_001188_SubHomePage.jsp • Oldways Preservation Trust (provides four additional cultural and ethnic food guide pyramids): http://oldwayspt.org/ • Vegetarian Resource Group: http://www.vrg.org

•

Science of nutrition • American College of Sport Medicine: http://www.acsm.org • Academy of Nutrition and Dietetics: http://www.eatright.org • American Heart Association: http://www.heart.org • National Center for Complementary and Integrative Health, National Institutes of Health: https://nccih.nih.gov • National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov

•

Adolescent nutrition: special conditions and interventions • American Heart Association (Children and Cholesterol): http://www.heart.org/HEARTORG/Conditions/Cholesterol/UnderstandYourRis kforHighCholesterol/Children-and-Cholesterol_UCM_305567_Article.jsp • American Medical Association (Public Health): https://www.amaassn.org/delivering-care/public-health • Bright Futures: http://www.brightfutures.org • Family Voices: http://www.familyvoices.org • Eating Disorder Referral and Information Center: http://www.edreferral.com • National Eating Disorders Association: http://www.nationaleatingdisorders.org/

•

Public food and nutrition programs • U.S. Department of Agriculture Food and Nutrition Information Center: http://fnic.nal.usda.gov/

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 15: Adolescent Nutrition: Conditions and Interventions

•

Nationwide priorities and nutritional health • United States—Weight-Control Information Network: http://www.niddk.nih.gov/health-information/health-communicationprograms/win/Pages/default.aspx [return to top]

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 16: Adult Nutrition

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 16: ADULT NUTRITION

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 5 Chapter Outline ................................................................................................................... 5 Discussion Questions.......................................................................................................... 8 Additional Activities and Assignments .............................................................................. 9 Additional Resources .........................................................................................................13 Internet Resources.................................................................................................................. 13

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to explore the nutritional needs of adults and nutrition guidance and interventions aimed at helping meet those needs. Adulthood is subdivided into the following segments: Early Adulthood, Midlife, the Sandwich Generation, and Later Adulthood. Lifestyle choices interact with genetic endowment, social forces, and environmental factors to determine years of life and quality of life. During adulthood, the focus is on preserving health, maintaining a healthy weight, and minimizing risks of and delaying or preventing the onset of chronic diseases.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 16.1

Discuss different types of nutrition-related risk factors and how they are monitored in adults.

16.2

Describe normal physiological changes in adulthood and how they are associated with the development and progression of chronic diseases.

16.3

Estimate your daily energy needs using three methods and discuss factors that affect energy needs of adults.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 16: Adult Nutrition

16.4

Identify nutrients that are consumed in excessive and inadequate levels and the consequences for adult health.

16.5

Explain the purpose of dietary guidance and how it translates science into healthful food and beverage choices and pleasurable eating experiences for adults.

16.6

Describe national recommendations for physical activity and the benefits of regular physical activity.

16.7

Contrast the multiple strategies used to promote and support good nutrition of adults.

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KEY TERMS Sandwich generation: Refers to middle-aged adults, usually women, who are multigenerational caregivers dealing with the complex roles of wife, mother, daughter, caregiver, and employee. Healthy weight: A weight range compatible with normal function and long, healthy life. Carcinogenic diet: A pattern of eating and food choices that increases the risk of some cancers. Atherogenic diet: A pattern of eating and food choices that promotes deposits of plaque in arterial walls and contributes to the development of cardiovascular disease. Obesogenic diet: A pattern of eating and food choices that leads to excessive energy intake and accumulation of body fat. Social determinants of health: Socioeconomic and environmental factors that are powerful determinants of health and are largely outside of the control of individuals and groups, but affect a wide range of health, functioning, and quality of life outcomes. Health disparity: Significant differences in the incidence, prevalence, mortality, and burden of disease and other adverse conditions that exist among specific population groups. Health disparity is closely linked to social and economic disadvantage. Health inequity: Significant differences in the incidence, prevalence, mortality, and burden of disease and other adverse conditions that exist among specific population groups that are avoidable, unnecessary, and unjust.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 16: Adult Nutrition

Lean body mass: Sum of fat-free body tissue; muscle, mineral (as in bone), and water. Climacteric change: Point in life where crucial changes occur; refers to the loss of reproductive activity, marked by menopause in women and reduction in testosterone production in men. Perimenopause and menopause: An approximately 4-year period of decreasing estrogen productions followed by the end of menstruation; a marking point for increased risk of cardiovascular disease and other chronic conditions for women. Energy balance: An equilibrium state in which the number of calories consumed equals the number of calories expended. Immunosenescence: A progressive decline in immune function, often evidenced by low-grade chronic inflammation. Adipose tissue macrophages (ATM): A type of cell within adipose tissue that switches in response to its microenvironment to be anti-inflammatory or pro-inflammatory. Cytokines: Small secreted chemical messenger proteins that function as immunomodulating agents. Some cytokines stimulate the immune system and others slow it down. Gut dysbiosis: Breakdown in the balance of protective and harmful bacteria and other microbes in the intestines. Continuum of Nutritional Health: Stages of nutritional status that range from optimal to unable to sustain life. The stages are resilient and healthy, altered substrate availability, nonspecific signs and symptoms, clinical conditions, chronic conditions, and terminal illness and death. Dietary guidance: Providing concise recommendations and consumer information to guide food choices. Basal metabolic rate (BMR): Amount of energy required for cellular metabolic processes and function of organs. It is measured in an individual who has been awake less than 30 minutes and is still at absolute rest, has fasted for 10 hours or more, and is in a quiet room with normal, comfortable temperature. Thermic effect of food (TEF): Energy required for the digestion, absorption, and metabolism of food; approximately 10 percent of energy needs. Activity thermogenesis: Energy expended through physical activity and nonexercise activity such as fidgeting. Estimated energy requirement (EER): The average dietary energy intake for adults in good health, by age, gender, weight, height, and level of physical activity, that is predicted to maintain energy balance and is consistent with good health.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 16: Adult Nutrition

Resting energy expenditure (REE): Measured or estimated energy expenditure in an individual at rest. Viscous fiber: Types of fiber characterized by their ability to form a gel solution when combined with liquid. Formerly called soluble fiber. Fermentable fiber: Type of fiber that enters the large colon undigested, where it is acted on by the bacteria of the gut. Formerly called insoluble fiber. Dietary guidance system: A comprehensive set of dietary and lifestyle recommendations, based on the latest scientific information, that are developed to promote health and prevent disease or its complications, ensure adequate intake of nutrients of concern, and offer guidance on what and how much to eat. Dietary Guidelines: A report, including scientific information and rationale, on dietary information and guidelines for the general public or a defined subpopulation. The guidelines provide a cohesive set of recommendations that are adopted by the government or organization. They represent policy and are integrated into food, nutrition, and health programs. Total diet approach: Guidance based on overall eating patterns that meet needs with a variety of foods over time. Nutrient-dense food: A food that provides substantial amounts of vitamins, minerals, and other biologically active food components with relatively few calories. Also called nutrient-rich food. Functional food: A food product that has a physiological benefit or reduces the risk of chronic disease beyond basic nutritional functions. Phenolic compounds: A large group of naturally occurring compounds in plant-based foods that contribute sensory qualities to food and health promoting benefits to the body. Also called polyphenols. Eating Competence Model: A paradigm for nutrition education and dietary guidance that considers four components: eating attitudes, food acceptance, regulation of food intake, and eating context. A competent eater is positive, comfortable, and flexible with eating and is matter-of-fact and reliable about getting enough enjoyable, nourishing food to eat. Active living movement: Building a culture where regular physical activity and healthy eating are the accepted norm for people of all ages, abilities, and income levels. Involves partnership of public and private entities and the local community to bring about changes. Ergogenic aids: Nutritional products that are purported to enhance performance. Examples range from caffeine and protein powders to sports drinks and energy gels and bars.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 16: Adult Nutrition

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WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • • • • • •

•

Updated statistics to reflect latest available information Added the term health inequity and differentiated it from health disparity Updated DRI for energy for adults Included the impact of gender-affirming interventions on body composition for transgender persons Added a section on immunosenescence and the relationship of adipose tissue with immune function and inflammation Incorporated the latest information from Dietary Guidelines for Americans, including concern about the contribution of beverages to excess caloric intake Noted newer alcohol consumption study findings that question the protective effect of moderate amounts of alcohol and raise concerns about binge drinking among younger adults Revised the Case Study to feature a Somali woman dealing with physical training and fasting during Ramadan

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CHAPTER OUTLINE I.

Introduction a. The transition from adolescence to adulthood occurs when periods of physical growth and development are, for the most part, complete. b. “Adulthood” is arbitrarily divided into early adulthood, midlife, and later adulthood, all of which often present similar nutritional needs. c. Chapter 16 “explores the nutritional needs of adults and nutrition guidance and interventions aimed at helping meet those needs.”

II.

Tracking Adult Nutritional Health and Its Determinants Discuss different types of nutrition-related risk factors and how they are monitored in adults. (LO 16.1) a. The Healthy People 2030 objectives for the United States are population based, although to achieve them, individuals must act. b. Healthy People 2030 objectives are referenced throughout the text, and Table 16.3 highlights goals pertaining to adults.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 16: Adult Nutrition

III.

Physiological Changes During the Adult Years Describe normal physiological changes in adulthood and how they are associated with the development and progression of chronic diseases. (LO 16.2) a. The focus of Chapter 16 is on adults up to age 64. b. Sensory changes start to occur after age 60. c. The greatest physiological changes are driven by hormonal shifts, leading to menopause in women and the less dramatic male climacteric. d. Women's heart health is protected by estrogen production. e. The six stages of a continuum of nutritional status are discussed and graphically depicted (Figure 16.3).

IV.

Energy Recommendations Estimate your daily energy needs using three methods and discuss factors that affect energy needs of adults. (LO 16.3) a. Changes in body weight during adulthood are related to many factors: gender, body size, muscle mass, activity levels, healthy status, hormones, and individual variation. b. The abundance of formulas for calculating energy needs (e.g., the Mifflin-St. Jeor Energy Estimation Formula and the older Harris-Benedict equation) reflects the need to determine exactly how many calories are required to achieve and sustain desired body weight. c. Losing 1 pound of body weight requires a deficit of approximately 3500 kilocalories. d. Losing body fat takes time, but gaining weight is also a slow process. e. Table 16.4 shows a comparison of calorie needs based on age, gender, and activity level.

Nutrient Recommendations Identify nutrients that are consumed in excessive and inadequate levels and the consequences for adult health. (LO 16.4) a. Table 16.5 shows data taken from NHANES 2017–2018 that summarizes the intake for selected nutrients by adults. b. From these data, the intakes of protein, total fat, saturated fat, and sodium were above the recommended levels. c. At the same time, the intakes for nutrients such as fiber, vitamin A, vitamin E, and several other vitamins and minerals were low. d. This section of the chapter expands on the specific functions of the nutrients for which intakes are too low based on the NHANES data.

VI.

Dietary Recommendations for Adults

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 16: Adult Nutrition

Explain the purpose of dietary guidance and how it translates science into healthful food and beverage choices and pleasurable eating experiences for adults. (LO 16.5) a. Dietary guidance systems are scientifically based nutritional recommendations that have the goal of promoting health and preventing disease. b. The Dietary Guidelines for Americans and the USDA’s ChooseMyPlate.gov website are two of the major dietary guidance systems available in the United States. c. It is important to keep in mind that food guidance systems assume that the nutrient-dense foods people choose to eat do not contain any additional sugar or fats—but often this is not the case, so the number of calories consumed increases. d. Another challenge is that portion sizes are overestimated on a regular basis, which also adds to the daily calories consumed. e. This section further discusses water and caloric beverage intakes, effects of caffeine, alcohol consumption, dietary supplements, and the Eating Competence Model. VII.

Physical Activity Recommendations Describe national recommendations for physical activity and the benefits of regular physical activity. (LO 16.6) a. Only 2.5 hours of physical activity every week can improve health! b. Physical activity guidelines for adults are listed in Table 16.10. c. The case study “Run, Jamilah, Run” deals with physical activity, but also requires students to summarize basic nutrition concepts of this chapter.

VIII.

Nutrition Intervention for Risk Reduction Contrast the multiple strategies used to promote and support good nutrition of adults. (LO 16.7) a. Scientists have identified nutritional habits that can reduce the risk of disease for adults (Table 16.1 is one type of summary of such habits). b. The challenge faced by the public is related to adopting behaviors linked to wellness and risk reduction. c. Success stories inspire others to renew their efforts, and this section describes a success story in the private sector. d. Food and nutrition assistance programs are briefly listed, and web resources can augment this section.

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 16: Adult Nutrition

DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class. 1. Many factors affect an individual’s energy needs. Name at least three factors that go into determining energy needs and elaborate on the effect each one has on dieting and weight loss. [Gender/body size/muscle mass (i.e., the more you weigh, the more calories you burn); activity levels; health status; hormones; and individual variation.] (LO 16.3) 2. Pass out notepaper or index cards and ask each student write down a food advice message. For example, “Raw vegetables are better for you than cooked” or “Eat carbohydrates before a race.” Collect the cards, scan for the most common or most interesting advice, and discuss three to four of these with the class. Ask several of the following questions to stimulate discussion: Have other students heard of this advice? Have they tried it? What were the circumstances that led the individual to try something new? Where do class members seek and get advice about what to eat? What makes them pay attention to a particular recommendation? What do they hope to gain from dietary advice? Summarize: There has never been a shortage of food guidance; for instance, prescriptions for dietary practice were a part of religious regulations in ancient times. The trick for nutritionists is to make advice relevant so that it is heard. Knowledge without action does not lead to better health. (LO 16.7) 3. What are the benefits of alcohol in a diet? What are the drawbacks? Should alcohol be considered an energy nutrient? Why or why not? (LO 16.5) 4. Nutrients of public health concern are those eaten in either insufficient or excessive amounts in a population. Based on Table 16.5, which, if any, of the nutrients are “risk nutrients”? (LO 16.4) 5. Based on NHANES data averages, over a third of an individual’s calories are eaten as energy-dense, nutrient-poor foods (sources of solid fats and added sugars). Among drinkers, another 16% are supplied by alcohol. What strategies would the students use to maximize nutrition in the nutrient-dense portion of their diets? (LO 16.5) 6. Vitamin and mineral supplements are used by roughly 44% of males and 53% of females in the United States. The most commonly found nutrients in those supplement products are ascorbic acid, vitamin B12, vitamin B6, niacin, thiamin, riboflavin, vitamin E, beta-carotene (vitamin A precursor), vitamin D, and folic acid. Compare this list to what is missing in the diets of the average adult [see Table 16.5]. How do the lists coincide? Is there any benefit or harm in taking overdoses of vitamins and minerals? (LO 16.4)

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 16: Adult Nutrition

7. Discuss the value of having Tolerable Upper Intake Levels specified for various nutrients. Suggest several circumstances under which one could ingest an excess of vitamin E, vitamin C, or calcium. [Some studies have examined the role of antioxidant vitamins that raise LDL cholesterol levels.] (LO 16.5)

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ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. Key Dietary Recommendation Documents (LO 16.5) Total Time: Will vary Requires homework: List key dietary recommendation documents on the board or via a projection system. Have each student sign up to examine one of these, making sure that at least two students have signed up for each. Ask students to follow their food guideline for one or more days. Ask them to keep a record of the questions or difficulties that arise. During the next class, have students form groups of three to four based on the tool they used, and prepare a short list of its pros and cons. Have them note three or four questions (one per student) raised by their use of the dietary guidance tool. For each of the dietary recommendation tools, have small groups present their assessments, including a selection of the questions raised during their use. When each tool has been discussed, ask the whole class to generate a list of features they want to see in an effective dietary guidance tool. Review attributes of good guidance. 2. Dietary Guidance Tool for Vegetarians (LO 16.5) Total Time: 30 minutes Break the class into small groups of four or five and ask each group to devise a dietary guidance tool for vegetarians. Ask half of the room to target vegans and the other half to target lacto-ovo vegetarians (Table 16.7). How will each group ensure that these guidelines can be used to meet the nutrient needs of their target audience? Have groups comment on (critique) each other’s tools. 3. Alcohol Guidelines (LO 16.5) Total Time: 40 minutes In-class writing: Alcohol guidelines vary around the world. Some countries count drinks, some count grams of alcohol, and others use percent of total calories to guide intake. Assign each student (or have them work in pairs) to develop an alcohol guidance statement that would be useful for a peer group. Would use of this guideline tell a driver whether they are impaired or okay to drive (i.e., are they likely to pass any blood alcohol tests)? Regarding the effects of blood alcohol concentration, review information from the CDC at: Drinking too much alcohol can harm your health. Learn the facts | CDC. Debrief the class: what features does an alcohol guidance tool need to be useful?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 16: Adult Nutrition

4. Complete Worksheet 16-1: Case Study—Osteoporosis Risk Reduction (LO 16.5) Total Time: 20 minutes Answers: 1. Participate in regular weight-bearing physical activity, reduce sodium intake to maximum of 2300 mg (UL), decrease caffeine intake (consider decaffeinated coffee), increase vitamin D intake to 15 g/day (RDA) 2. Divide the dose to 500 mg at a time and take it with meals or a large snack to increase absorption. 3. Answers will vary, but could include the Academy of Nutrition and Dietetics: www.eatright.org; National Osteoporosis Foundation: http://www.nof.org/; and Medline Plus: http://www.nlm.nih.gov/medlineplus/osteoporosis.html. 4. Calcium- and vitamin D-fortified orange juice, calcium- and vitamin D-fortified soy milk or cheese, calcium-set tofu, broccoli, spinach, kale, and calcium-and vitamin D-fortified breakfast cereals.

5. Complete Worksheet 16-2: Estimating the Calorie and Fluid Requirements of Adults (LO 16.2) Total Time: 30 minutes 1. Males: [REE = (10  wt) + (6.25  ht) – (5  age) + 5]  1.55 Males: [REE = (10  79.5) + (6.25  177.8) – (5  52) + 5]  1.55 = 2559 calories 2. Females: [REE = (10  wt) + (6.25  ht) – (5  age) – 161]  1.2 Females: [REE = (10  56.8) + (6.25  157.5) – (5  34) – 161]  1.2 = 1466 calories 3. 2559 mL fluid 4. 79.5 kg  30–40 mL/kg = 2385–3180 mL fluid 5. Wider range of estimated fluid requirements and a lower starting point for the 30–40 mL/kg method

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 16: Adult Nutrition

Worksheet 16-1: Case Study—Osteoporosis Risk Reduction Mary is a 53-year-old woman who just started menopause. She is concerned about her risk for developing osteoporosis because her neighbor shattered her tailbone last week. Mary has always been health conscious, but she knows her dietary habits could be improved. She started taking calcium carbonate supplements (1200 mg) just like her neighbor, right before bed. Her three-day food record was evaluated using a computerized nutrient analysis program, and here are the results.

Calories: Fat: Protein: Sodium: Calcium: Caffeine: Vitamin D:

2257 135 grams 111 grams 4512 milligrams 832 milligrams 1200 milligrams 7 micrograms

Questions: 1. Following which recommendations could help decrease Mary’s risk for developing osteoporosis?

2. How can Mary receive the most benefit from her calcium supplements?

3. Mary would like your recommendations for a website to learn more about preventing osteoporosis. What suggestions do you have?

4. Access the patient education materials for osteoporosis at www.nof.org/. What foods would you recommend Mary eat to reduce her osteoporosis risk if she is a vegan?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 16: Adult Nutrition

Worksheet 16-2: Estimating the Calorie and Fluid Requirements of Adults

Directions: Use the information in Chapter 16 to complete this worksheet.

1. Use the Mifflin-St. Jeor Energy Estimation Formula to calculate the estimated calorie requirements for a moderately active 52-year-old man who weighs 79.5 kg and is 177.8 cm tall.

2. Use the Mifflin-St. Jeor Energy Estimation Formula to calculate the estimated calorie requirements for a sedentary 34-year-old woman who weighs 56.8 kg and is 157.5 cm tall.

3. Using the 1 mL water per calorie of food ingested method, estimate the fluid needs for the male in question #1.

4. Using the 30–40 mL of fluid/kg method, estimate the fluid needs for the male in question #1.

5. How do the estimated fluid needs differ between the two sets of equations?

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 16: Adult Nutrition

ADDITIONAL RESOURCES INTERNET RESOURCES •

General nutrition • Calorie Control Council: http://www.caloriecontrol.org • Cyberdiet: http://www.cyberdiet.com • Oldways Preservation Trust (provides four additional cultural and ethnic food guide pyramids): http://oldwayspt.org/ • Vegetarian Resource Group: http://www.vrg.org

•

Science of nutrition • Academy of Nutrition and Dietetics: http://www.eatright.org

•

Adult nutrition • Agency for Healthcare Research and Quality (Living a Healthy Lifestyle): https://innovations.ahrq.gov/issues/2016/03/16/innovations-promotehealthy-living • American Heart Association: http://www.heart.org • National Cancer Institute, Cancer Information Service: http://www.cancer.gov/ • CDC Division of Nutrition, Physical Activity, and Obesity: http://www.cdc.gov/physicalactivity/resources/reports.html • U.S. Preventive Task Force’s Evidence Review (Behavioral Counseling to Promote Physical Activity and a Healthful Diet to Prevent Cardiovascular Disease in Adults): http://www.ncbi.nlm.nih.gov/books/NBK51030/ • National Center for Complementary and Integrative Health, National Institutes of Health: https://nccih.nih.gov/

•

Nationwide priorities and nutritional health • Statistics • Census Bureau (American Fact Finder): http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml • Centers for Disease Control and Prevention (Morbidity and Mortality Weekly Report): http://www.cdc.gov/mmwr/ • United States • Department of Agriculture, Center for Nutrition Policy and Promotion: http://www.cnpp.usda.gov/ • Environmental Protection Agency (ground water and drinking water): http://water.epa.gov/drink/index.cfm • Food and Drug Administration: http://www.fda.gov

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 17: adult nutrition: Conditions and interventions

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 17: ADULT NUTRITION : CONDITIONS AND INTERVENTIONS

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 4 Chapter Outline ................................................................................................................... 4 Discussion Questions.......................................................................................................... 6 Additional Activities and Assignments .............................................................................. 7 Additional Resources .........................................................................................................13 Internet Resources.................................................................................................................. 13

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to discuss obesity and then address the three nutrition-related diseases that are the highest contributors to premature death among adults: cancer, cardiovascular diseases, and diabetes. The chapter highlights the interrelatedness of chronic diseases and outlines the risk factors that these diseases have in common.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 17.1

Analyze the multiple causes of obesity and how they relate to nutrition assessment and intervention for adults.

17.2

Explain how atherosclerosis is the basis for cardiovascular diseases and how assessment and intervention are used for prevention and treatment of CVD.

17.3

Describe metabolic syndrome and its assessment and effects.

17.4

Differentiate the types of diabetes and how they are diagnosed and managed.

17.5

Describe the development of cancer and contrast nutrition assessment and intervention priorities at each of the four stages of cancer care.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 17: adult nutrition: Conditions and interventions

KEY TERMS Metabolic obesity: Body weight set point shifts to a higher level due to alterations of the energy balance system. Hedonic obesity: Body weight maintained above set point due to sustained overeating. Precision nutrition: An approach to developing more targeted and effective diet interventions based on an individual’s personal genetic and metabolic characteristics. Obesogenic environment: The sum of influences that promote overeating and minimize physical activity and lead to weight gain and hinder weight loss. Meal replacement: A nutritionally balanced beverage, meal bar, or packaged meal used to replace a meal in weight management. Intermittent fasting: A regimen of reoccurring periods of fasting followed by periods of unrestricted eating. Time-restricted eating: A dietary approach that consolidates all calorie intake to 6-t 12-hour periods during the active phase of the day, without necessarily altering the diet quality and quantity. Cognitive behavioral therapy: Programs designed to build knowledge, modify beliefs and attitudes, and integrate new behaviors through a combination of skills training and analysis of behavior and through processes over a period of several weeks. Key features are cognitive restructuring and stimulus control. Energy gap: The required change in energy expenditure relative to energy intake necessary to restore energy balance. Comorbidity: The presence of one or more diseases or conditions in addition to the primary disease or disorder. Ischemia: Inadequate blood supply to a local area due to partial or complete blockage of a blood vessel. Cardiovascular health score (CVH): A composite number based on seven measurable and modifiable medical and behavioral factors related to CVD: total cholesterol, blood pressure, fasting glucose, BMI, diet, physical activity, and smoking. Primordial prevention: Actions to prevent development of a disease risk factor through very early intervention including pregnancy, infancy, childhood, and young adulthood. Atherosclerosis: A disease of the arterial blood vessels (arteries) in which the walls of the blood vessels become thickened and hardened by cholesterol and calciumcontaining plaque.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 17: adult nutrition: Conditions and interventions

Dyslipidemia: Abnormal blood levels of cholesterol and/or triglycerides resulting from altered lipid metabolism. Dysglycemia: An abnormality in blood glucose stability. Therapeutic lifestyle change: A higher-intensity intervention approach with focus on sustained behavior changes to reduce risk and slow disease progression among highrisk individuals. Often includes individual, group and virtual components delivered through clinic or community organizations over a period of months. Cardio-protective diet: A diet that emphasizes plant foods (vegetables, fruits, grains, especially whole grains, and legumes), appropriate fats and fish, along with smaller amounts of lean meat and dairy. Pharmacotherapy: Treatment of disease through the use of drugs. Hyperinsulinemia: A state of excess levels of insulin circulating in the blood. It is common among persons with metabolic syndrome and type 2 diabetes and is caused by the pancreas trying to compensate for insulin resistance of cells. Hyperglycemia: Abnormally high levels of glucose in the blood. Prediabetes: A condition in which blood glucose levels are higher than normal but not high enough for the diagnosis of diabetes. This intermediate hyperglycemia state is characterized by impaired glucose tolerance, fasting blood glucose levels between 100 and 125 mg/dL or elevated A1c. Patient-centered care: An approach to care that considers the individual’s medical issues as well as social determinants of health factors, while being respectful of, and responsive to, the patient’s preferences, needs, and values and including them in all clinical decisions. Diabetes self-management education and support (DSMES): An ongoing process of individualized education and support to facilitate the knowledge, skill, and ability necessary for prediabetes and diabetes self-care and quality of life. Eating plan: A plan for timing of meals and snacks and types and amounts of foods eaten to achieve nutrition goals. Carcinogenesis: The process by which normal cells are transformed into cancer cells. It includes activation, initiation, promotion, progression, and invasion and metastasis. Dietary constituents can modify the process at several points along the continuum. Anorexia: Loss of desire to eat or aversion to food related to disease, treatment, and/or emotional distress. Cachexia: A complex metabolic syndrome characterized by progressive loss of body weight, fat and muscle, systemic inflammation, and negative protein and energy balance.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 17: adult nutrition: Conditions and interventions

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WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: •

• • • • • •

• •

Definitions and content for precision nutrition, metabolically healthy obesity, intermittent fasting, time-restricted eating, cardiovascular health score, and primordial prevention Special considerations in the screening and management of obesity and chronic conditions among transgender persons and gender minorities Expanded content to distinguish between metabolically healthy obesity and unhealthy obesity Expanded assessment of obesity to include visceral fat assessment and body composition Updated obesity and diabetes sections to incorporated latest evidence-based recommendations Revised bariatric surgery section, including its broader application to metabolic disease Emphasis on preserving health through earlier, upstream action, including consideration of the social determinants of health, and culturally relevant, personalize intervention, with special initiatives to reach underserved and vulnerable populations Emphasis on the role of intensive, multicomponent interventions for weightmanagement and chronic disease intervention to bring about lifestyle change Notation of cancer disparities experienced by persons in marginalized populations, and new initiatives to improve cancer screening, diagnosis, treatment and outcomes for these populations Revised Table 17.1 to contrast causes of death by decades of the adult years Removed section on HIV/AIDS

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CHAPTER OUTLINE I.

Introduction a. The leading causes of death in the United States are chronic diseases, many of which are related to lifestyle choices. b. Review of these (CVD, overweight, and obesity) is continued in Chapter 19.

II. Overweight and Obesity

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 17: adult nutrition: Conditions and interventions

Analyze the multiple causes of obesity and how they relate to nutrition assessment and intervention for adults. (LO 17.1) a. Increasingly common, overweight and obesity are among the most complex nutrition-related conditions affecting adults. b. Seemingly simple advice to “consume less, burn more” forms the basis of many weight-loss interventions, although if it were that easy, there would not be a multi-billion-dollar weight-loss industry. c. The urgency to develop and adopt effective weight-maintenance interventions is supported by examining the definitions of “overweight” and “obesity” and concurring prevalence data. d. Components of successful weight-management programs are discussed. III. Cardiovascular Disease Explain how atherosclerosis is the basis for cardiovascular diseases and how assessment and intervention are used for prevention and treatment of CVD. (LO 17.2) a. As the leading causes of death for all adults, heart disease and stroke are singled out by Healthy People 2030; see Tables 17.5 and 17.6. b. Early intervention has the greatest potential to reduce cardiovascular diseases, and there are potentially modifiable risk factors. c. Risk factors are assessed in several ways; key approaches are anthropometric and biological measures, chemistry and laboratory values, and dietary intake. Each of these assessments could easily serve as the basis for a lecture, although the related nutrition interventions (including integrative approaches) make for an equally imposing list. d. This section offers an opportunity to distinguish among primary, secondary, and tertiary prevention. e. TLC is an apt acronym for therapeutic lifestyle change, the dietary changes recommended by the National Cholesterol Education Program (NCEP) and the American Heart Association (AHA). IV. Metabolic Syndrome Describe metabolic syndrome and its assessment and effects. (LO 17.3) a. Metabolic syndrome (also known as syndrome X or the dysmetabolic syndrome) is a cluster of symptoms associated with a high risk of coronary artery disease, stroke, and type 2 diabetes. b. The prevalence of, etiology of, effects of, and nutrition interventions for metabolic syndrome are discussed. V. Diabetes Mellitus Differentiate the types of diabetes and how they are diagnosed and managed. (LO 17.4) a. Each type of diabetes is defined and discussed.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 17: adult nutrition: Conditions and interventions

b. The prevalence of type 2 diabetes continues to increase, together with rising rates of obesity. The etiology of type 2 diabetes is reviewed. c. Insulin resistance can be linked to the concept of the glycemic index of foods discussed in Chapter 1. d. The relationships among risk factors and intervention strategies for heart disease, diabetes, obesity, and metabolic syndrome provide opportunities to push students to think holistically. e. Risk factors and nutrition interventions for type 2 diabetes are provided. VI. Cancer Describe the development of cancer and contrast nutrition assessment and intervention priorities at each of the four stages of cancer care. (LO 17.5) a. “Cancer is a group of diseases in which genes malfunction, resulting in unregulated cell growth and tumor formation,” making this topic difficult to summarize. b. Many of the risks factors for developing cancer are closely related to lifestyle choices (e.g., smoking, obesity, physical inactivity). c. Alternative medicine cancer treatments are evaluated by the National Cancer Institute and the National Center for Complementary and Alternative Medicine, both of which provide up-to-date information regarding complementary and alternative treatments. [return to top]

DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class. 1. Based on Table 17.6, which ethnic group is at greatest risk for coronary heart disease (CHD)? For stroke? Which ethnic group is least vulnerable to heart disease and to stroke? [To go further, examine the obesity statistics in the Healthy People 2030 document for these same ethnic groups and explain potential relationships.] (LO 17.2) 2. Identify the laboratory values used to define risk factors for CVD. Clarify questions, if any; then ask students to generate dietary interventions for each of the modifiable risk factors. Have they ever tried to modify their own diets? What advice could they offer to an individual needing to make a dietary behavior change? (LO 17.2)

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 17: adult nutrition: Conditions and interventions

3. Have students calculate their own BMI by the nonmetric and metric formulas. How do the BMI values compare? What do students need to know to interpret their BMI number? (LO 17.1) 4. What constitutes a healthy or normal BMI? What are some of the reasons it is useful to have a single number, such as a BMI, to describe a height/weight relationship? What are the drawbacks? (LO 17.1)

5. What are the components of a successful weight-loss program based on cognitive behavioral therapy? Ask students to cite examples of programs with which they are familiar and have the class evaluate them based on the components mentioned. [See the list on pp. 428–429, which includes realistic goals, caloric deficit, meal plan, skill development, and so on.] (LO 17.1) 6. Ask students whether they consider obesity to be a disease. If yes, what weightmanagement services would they like to see insurance carriers cover? If they do not consider obesity to be a disease, why not? (LO 17.1)

7. Patients with cancer often seek complementary care, as seen by the number of products sold to ameliorate or “cure” cancer. Discuss how health professionals and cancer patients can identify products that work and avoid those that might cause harm. (LO 17.5) [return to top]

ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. Imaginary Heart-Health or Weight-Loss Product (LO 17.1 and 17.2) Total Time: Will vary Requires homework: Have each student partner with another student to develop an imaginary heart-health or weight-loss product and advertisement. Have students share their products and slogans in class. Summarize this activity by discussing levels of evidence for product efficacy. 2. Regular Versus Reduced Fat or Fat-Free Products (LO 17.2) Total Time: 30 minutes Divide the class into teams of 2. Instruct them to visit a grocery store and compare labels between regular and reduced-fat or fat-free products. Suggestions for product comparisons are regular and fat-free (or low-fat) peanut butter, cookies, salad dressing, ice cream fudge topping, breakfast cereal, yogurt, milk, tortilla chips, and snack crackers. Which foods had the same number of calories despite a reduction in fat? Have the class generate potential recommendations for individuals inquiring about special products.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 17: adult nutrition: Conditions and interventions

3. The Rising Prevalence of Metabolic Syndrome and Diabetes (LO 17.3 & 17.4) Total Time: 35 minutes Metabolic syndrome and diabetes prevalence are increasing. Have students form small groups and role-play food-related discussions during a visit home over the Thanksgiving weekend. Each group should include at least 2 people but could include observers to offer feedback on the interactions or assign additional family members who may be overweight. The scenario is that the student learns that one of their parents (or a visiting grandparent) has been diagnosed with type 2 diabetes. The parent or grandparent wants to ask the student what they have learned about nutrition and diabetes while away at college, potentially to apply this information. 4. Complete Worksheet 17-1: Case Study—Nutrition Intervention for Hyperlipidemia (LO 17.2) Total Time: 20 minutes Answers: 1. 30.6 kg/m2 2. BMI >30 kg/m2, waist circumference >35 in., HDL cholesterol level at the minimum recommended, LDL cholesterol level high, total cholesterol level high risk, low fruit and vegetable intake, family history of vascular diseases, stress from being the primary caregiver for two family members, low fiber intake 3. Nutrition education recommendations include reducing dietary sources of saturated fat, increasing dietary fiber and fruit and vegetable intakes, and continuing weight reduction. Encourage exercise, and investigate the incorporation of plant stanols into the diet. 5. Complete Worksheet 17-2: Heart Healthy Nutritional Requirements (LO 17.2) Total Time: 30 minutes Answers: 1. Females: [REE = (10  wt) + (6.25  ht) – (5  age) - 161 Females: [REE = (10  72.7) + (6.25  172.7) – (5  58) – 161 = 1355 calories Total calorie needs = REE  1.55 activity factor (moderate activity level) = 2100 calories 2. Saturated fat = 0.07  2100 calories = 147 calories  9 calories per gram = <16.3 grams Monounsaturated fat = 0.20  2100 calories = 420 calories  9 calories per gram = <46.7 grams Polyunsaturated fat = 0.10  2100 calories = 210 calories  9 calories per gram = <23.3 grams

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 17: adult nutrition: Conditions and interventions

3. Total fat = 0.25–0.35  2100 calories = 525–735 calories  9 calories per gram = 58–82 grams 4. Carbohydrates = 0.50–0.60  2100 calories = 1050–1260 calories  4 calories per gram = 263–315 grams 5. 1 pound = 3500 calories  7 days in the week = 500 calorie daily deficit 2100 = estimated daily calorie need – 500 calories = 1600 calories 6. 2 pounds = 7000 calories  7 days in the week = 1000 calorie daily deficit – 200 calories provided by physical activity = 800 calorie daily deficit 2100 = estimated daily calorie need (midpoint) – 800 calories = 1300 calories 7. No. It’s difficult to meet your daily nutrient requirements from food with fewer than 1500 calories per day.

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 17: adult nutrition: Conditions and interventions

Worksheet 17-1: Case Study—Nutrition Intervention for Hyperlipidemia Florence, 58 years old, has been healthy all of her adult life until recently. Two months ago, she had her gallbladder removed for an acute gallstone attack. This was her first surgery. She was told this week by her physician that she has high cholesterol and needs to pursue dietary treatment for six weeks. At the end of six weeks, her cholesterol will be retested and her physician will make a decision regarding the possible prescription of lipid-lowering medications. Florence is very disappointed by this second health concern in such a short amount of time. She is 30 pounds lighter than she was last year, when her cholesterol was normal. Both of her parents passed away from vascular diseases. For exercise, Florence attends resistance training classes three times a week and is starting to do cardio exercise (walking). Florence is currently 5 feet 8.25 inches and weighs 203 pounds. Her waist circumference is 38.5 inches. Her most recent labs were: total cholesterol = 252 mg/dL, LDL cholesterol = 166 mg/dL, HDL cholesterol = 40 mg/dL, triglycerides = 133 mg/dL. She expresses the need to get better, as she is the primary caregiver for an adult son with schizophrenia and for her husband, who is ill with complications from diabetes. Her food recall shows a limited intake of fruits and vegetables, approximately 15 grams of fiber daily, limited dairy intake, and frequent consumption of foods high in saturated fat.

Questions: 1. What is Florence’s BMI?

2. What risk factors for coronary heart disease (CHD) are present in this case?

3. List dietary recommendations to assist with lowering her cholesterol levels and reducing her risk for CHD.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 17: adult nutrition: Conditions and interventions

Worksheet 17-2: Heart Healthy Nutritional Requirements Directions: Using the information from Chapter 16 and Chapter 17 on nutrition interventions for cardiovascular disease, complete this worksheet.

1. Use the Mifflin–St. Jeor Energy Estimation Formula (Chapter 16, p. 408), calculate the estimated calorie requirements for a 58-year-old female who is 5 feet 8 inches, 160 pounds, and moderately active.

2. Calculate the maximum amounts of saturated fat, monounsaturated fat, and polyunsaturated fat (in grams) that this person should consume.

3. Calculate the amount of total fat (in grams) that this person would require.

4. Calculate the amount of carbohydrates (in grams) that this person would require.

5. How many calories per day should this person consume to promote weight loss of one pound per week?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 17: adult nutrition: Conditions and interventions

6. Taking into account the expenditure of 200 calories per day in physical activity, how many calories should this person consume daily to promote weight loss of two pounds per week?

7. Do you recommend the calorie level estimated in question #6? Why or why not?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 17: adult nutrition: Conditions and interventions

ADDITIONAL RESOURCES INTERNET RESOURCES •

•

Science of nutrition • Academy of Nutrition and Dietetics: htpp://www.eatright.org

•

Adult nutrition: conditions and interventions • American Cancer Society: http://www.cancer.org • American Heart Association: http://www.heart.org • National Cancer Institute: http://www.cancer.gov/ • National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov/ • Heart Risk Calculator: http://www.cvriskcalculator.com/ • National Cholesterol Education Program: http://www.nhlbi.nih.gov/health/resources/heart/cholesterol-tlc • Obesity Society: http://www.obesity.org • The CDC National Center for Chronic Disease Prevention and Health Promotion (The Power of Prevention: Chronic disease... the public health challenge of the 21st century): http://www.cdc.gov/chronicdisease/pdf/2009-Power-ofPrevention.pdf

•

Nationwide priorities and nutritional health • Statistics • Census Bureau (American Fact Finder): http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml • Centers for Disease Control and Prevention (Morbidity and Mortality Weekly Report): http://www.cdc.gov/mmwr • United States • Department of Agriculture, Center for Nutrition Policy and Promotion: http://www.cnpp.usda.gov/ • Environmental Protection Agency (Ground Water and Drinking Water): http://water.epa.gov/drink/index.cfm • Food and Drug Administration: http://www.fda.gov

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 17: adult nutrition: Conditions and interventions

•

National Center for Complementary and Integrative Health, National Institutes of Health: http://nccam.nih.gov/ [return to top]

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 18: Nutrition and older adults

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 18: NUTRITION AND OLDER ADULTS

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 3 Chapter Outline ................................................................................................................... 4 Discussion Questions.......................................................................................................... 7 Additional Activities and Assignments .............................................................................. 9 Additional Resources ........................................................................................................ 14 Internet Resources.................................................................................................................. 14

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to define aging and provide information about the nutrient requirements, dietary recommendations, and food and nutrition programs designed to support healthy aging. Good nutrition can help “add life to years” as well as add years to life.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 18.1

Distinguish three or more reasons why functional status is a better indicator of health in older adults than chronological age.

18.2

Discuss the distinctions between life expectancy and life span, and address implications for society of increases in both.

18.3

Defend the statement: consequences of aging.”

18.4

List five physiological changes occurring at ages 70+ and describe nutritional implications for each.

“Diseases

and

disabilities

are

not

inevitable

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 18: Nutrition and older adults

18.5

Describe the relative effectiveness of two nutrition screening and assessment tools.

18.6

Relate how enjoying a varied diet contributes to mental and physical well-being.

18.7

Compare nutrient recommendations of old and young adults, citing five or more nutrients of concern for older populations.

18.8

Explain how good food-safety practices contribute to the health of older adults, and how increasing functional decline can be accommodated.

18.9

Summarize the heterogeneity of older adult populations and suggest two or more reasons to tailor health promotion.

18.10 Describe one or more nutrition programs serving older adults.

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KEY TERMS Longevity: Length of life, measured in years. Compression of morbidity: Shortening the period of illness and decreased functional capabilities at the end of life. Medicare: Federal health insurance for all people age 65 and older, and for younger individuals with certain disabling conditions. Life expectancy: Average number of years of life remaining for persons in a population cohort or group; most commonly reported as life expectancy from birth. Demographic transition: Transition from high birth and death rates to low birth and death rates. Life span: Maximum number of years someone might live; human life span is projected to range from 110 to 120 years. Centenarian: Person who reaches age 100 or more. Supercentenarian: Person who has reached age 110 or more, validated. Senescence: The condition or process of deterioration with age. Telomere: A caplike structure that protects the ends of chromosomes; it erodes during replication. Calorie restriction: Decreasing the energy level of one’s diet by 25–30% while meeting protein, vitamin, and mineral needs.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 18: Nutrition and older adults

Resilience: Ability to bounce back, to deal with stress, and recover from injury or illness. Fat-free mass: Used interchangeably with lean body mass, comprising bone, muscle, and water. Sarcopenia: Age-associated loss of skeletal muscle mass and function. Functional status: Ability to perform daily activities to meet basic needs and live independently, including telephoning, grocery shopping, food preparation, and eating. USP (United States Pharmacopeia): A nongovernmental, nonprofit organization (since 1820); establishes and maintains standards of identity, strength, quality, purity, processing, and labeling of healthcare products. NSF: International, a nongovernmental, nonprofit that also tests dietary supplements. Nutraceutical: Combination of words nutrient and pharmaceutical to indicate a foodderived compound that can act as a drug, such as red yeast rice, a statin-like compound. [return to top]

WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • • • • • • • • • • • • •

Updated statistics of all sections and their corresponding references Revised life expectancy section Updated Healthy People (HP) to include HP 2030 Revised section on Dietary Recommendations for Older Adults and replaced the Dietary Guidelines (DG) 2015–2020 with DG 2020–2025 Deleted Tufts University and University of Florida MyPlate for older adults and replaced with USDA MyPlate for different life stages Added new estimated energy requirement equations released by the National Academies of Sciences, Engineering and Medicine in 2023 Revised fat and cholesterol section Updated nutrient intake sections Added 2018 Physical Activity Guidelines for Americans Revised community food and nutrition programs section Deleted store-to-door nongovernmental small food program Revised and updated most tables and deleted illustrations 18.4 and 18.5 Deleted Appendix A Provided updated DRI for energy for older adults

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 18: Nutrition and older adults

CHAPTER OUTLINE I.

Introduction a. Diet quality is linked to longevity in older men and women. b. Who counts as “old”? For the purposes of Chapter 18, it is someone aged 65 or older, although this age is not consistently used in programs or for data reporting. c. The DRIs (inside the book cover) make recommendations for ages 51–70 and then older than age 70. d. Food and nutritional habits that add life to years as well as years to life are the focus of Chapters 18 and 19.

II.

A Picture of the Aging Population: Vital Statistics Distinguish three or more reasons why functional status is a better indicator of health in older adults than chronological age. (LO 18.1) a. People tend to live longer in Monaco and several other countries than in the United States or Canada (Table 18.1). b. Examining vital statistics highlights the need to learn terms such as longevity, life expectancy, and life span when learning about the nutritional health of older adults. c. The Healthy People 2030 food and nutrition goals for older adults are included in Table 18.2.

III.

Theories of Aging Discuss the distinctions between life expectancy and life span, and address implications for society of increases in both. (LO 18.2) a. It’s an age-old question: why do we get old, and more importantly, what can we do to slow (if not stop) the aging process? b. Theories are grouped into three main categories: (1) genes are programmed to stop physiological function, (2) wear and tear leads to eventual death, and (3) caloric restriction with adequate micronutrients leads to greater longevity in animals. c. The great majority of calorie restriction experiments have been conducted with animal subjects such as fruit flies, rodents, and primates. d. This part of the chapter also describes a very small study conducted on calorie restriction in humans and another that observed hormone level differences between adults based on calorie intakes.

IV.

Physiological Changes Defend the statement: “Diseases and disabilities are not inevitable consequences of aging.” (LO 18.3) a. Table 18.3 lists age-associated physiological system changes that impact nutritional health.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 18: Nutrition and older adults

b. The shift in body composition (Table 18.4; more fat, less muscle, and less water) has the greatest implications for nutrition. c. Slow, steady weight gain is common. d. In the Fels Longitudinal Study, men gained 0.7 lb per year, and women gained 1.2 lb as they aged. The composition of this gain was moderated by exercise. e. Illness, medications, and increasing age contribute to a decline in senses (especially of taste and smell). f. Acuity in thirst and appetite cues declines with age in men and women. V.

Nutritional Risk Factors List five physiological changes occurring at ages 70+ and describe nutritional implications for each. (LO 18.4) a. An exploration of the factors that make up the DETERMINE Checklist (Table 18.5 and Figure 18.2), including the weights assigned, will summarize the most important nutritional risk factors for older adults.

VI.

Dietary Recommendations for Older Adults Describe the relative effectiveness of two nutrition screening and assessment tools. (LO 18.5) a. This section is prefaced with “old age is not a disease.” b. Dietary recommendations from the USDA and HHS Dietary Guidelines for Americans (DGA) are based on age categories and physical activity level. c. Table 18.7 offers advice on how to eat well and drink adequate fluids at calorie levels ranging from 1600 to 2400 kcal. d. Older adults consume nearly ¼ of their energy from snacks, which are often sources of solid fats and added sugars, alcohol, and protein.

VII.

Nutrient Recommendations Relate how enjoying a varied diet contributes to mental and physical well-being. (LO 18.6) a. The average daily intakes of nutrients compared to recommended intakes are provided in Tables 18.10 and 18.11. b. Fiber plays many roles in the health of older adults, and suggestions for increasing fiber intake are included in Tables 18.12 and 18.13. c. Water and other fluid recommendations for older adults are discussed. (Further reading on water needs of adults could be an article by A Raman, DA Schoeller, AF Subar et al. “Water turnover in 458 American adults 40-79 yrs of age.” Am J Physiol Renal Physiol, Vol 286:F394-F401, Feb 2004, available at: http://www.ncbi.nlm.nih.gov/pubmed/14600032) d. Highlighted nutrients include vitamins A, D, E, K, B12; folic acid; iron; calcium; magnesium; and potassium. e. Reviewing the vitamin-mineral supplement section with students, especially the Nutrition/Supplement Facts label information (Table 18.16), can help to

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 18: Nutrition and older adults

clarify the unique aspects of nutrient recommendations for adults over age 70 (age 70, not 65, is a benchmark for the DRIs). f. Table 18.15 reviews dietary supplements potentially used by older adults and their associated health conditions. VIII.

Food Safety Recommendations Compare nutrient recommendations of old and young adults, citing five or more nutrients of concern for older populations. (LO 18.7) a. Older adults are at increased risk for foodborne illness because of the decreased immune system function commonly seen in the elderly. b. Risk reduction strategies are provided (p. 475).

IX.

Physical Activity Recommendations Explain how good food-safety practices contribute to the health of older adults, and how increasing functional decline can be accommodated. (LO 18.8) a. “Use it or lose it” especially applies to aging adults, who must do resistance training/activities if they are to maintain muscle mass. b. Reasons for not exercising include fear of getting hurt or exacerbating an illness. Table 18.17 suggests who can keep moving safely and who needs a doctor’s visit first. c. Exercising moderately for at least 150 minutes per week applies to older adults as well as to younger ones.

Nutrition Policy and Intervention for Risk Reduction Summarize the heterogeneity of older adult populations and suggest two or more reasons to tailor health promotion. (LO 18.9) a. Knowing what to do is one thing, and doing it is another. b. Many older adults know they “should drink more water,” but they don’t believe it matters and they are afraid they might need to go to the bathroom more. c. In order to change dietary behaviors, individuals need certain attitudes and skills: commitment to change, cognition to understand how, capability to carry out new skills, and confidence that the behavior change can be mastered. d. Effective nutrition education addresses each element.

XI.

Community Food and Nutrition Programs Describe one or more nutrition programs serving older adults. (LO 18.10) a. Several government and nongovernmental programs are discussed in this section.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 18: Nutrition and older adults

b. The Older Americans Act Nutrition Programs (OAANP), administered by the U.S. Department of Health and Human Services, is a food and nutrition program serving older adults around the nation. c. Part of its success has been due to meeting client needs for socialization as well as food, as well as providing home-delivered meals to those who cannot attend a dining site. d. Visiting a dining site can be a wonderful experience to make this program come alive for students (and possibly the instructor). e. This section concludes with a brief discussion of longevity and aging research. f. In particular, areas of the world that see longer life spans are of interest to researchers (e.g., Dan Buettner). g. A book by Buettner, The Blue Zones, offers a list of nine healthy living characteristics observed in world regions that have especially high numbers of centenarians (i.e., “The Blue Zones” of the world). The list is presented on p. 477. [return to top]

DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class. 1. Jeanne Calment is the oldest living woman on record. She lived (in France) to age 122. Who is the oldest person anyone knows? Does anyone know a centenarian? Clarify the terms life expectancy and life span. Which countries have the leading life expectancies for females? For males? Which have the lowest life expectancies? (LO 18.1)

2. Of the three approaches to theories on aging, which seems the most plausible? What are the reasons the student chose that theory of aging and not another? What are the implications for nutrition? (LO 18.1)

3. Discuss the implications of body composition changes (Table 18.4) for dietary intake and nutritional health. [For example, fewer calories needed, less energy and strength when muscle is lost, less resilience, easier to get dehydrated, inaccurate BMI values when dehydrated] (LO 18.3)

4. Compare the adequacy of protein intake for younger and older adults: who is most likely to be vulnerable to protein malnutrition? Population intake levels are

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 18: Nutrition and older adults

available from national surveys (Tables 18.10 and 18.11). What are questions you would ask an individual to evaluate their protein intake? (LO 18.6)

5. Tables 18.12 and 18.13 show fiber values of foods. Under what circumstances is it difficult to meet fiber recommendations? [Students will need to know what the age-specific fiber recommendations are.] On average, what is the fiber intake of older adults? Pretend you are over age 75, eating your current diet: how might you adjust your diet to meet the fiber recommendations, assuming that it does not meet them now? (LO 18.6)

6. You are asked to talk to a group of seniors about vitamins and minerals and want to be prepared to answer questions from your audience. What are some potential questions you’ll practice answering? Devise answers in class. Some examples are provided below. (LO 18.6) a. “I’ve heard that it is better to get your vitamins and minerals from food; is that true?” [Yes, generally. But older adults absorb synthetic B12 and folic acid more easily. Fortified foods contain synthetic forms of vitamin B12 and folic acid.] b. “Is it true that raw vegetables are better for you than cooked?” [Not always. For example, beta-carotene and lycopene are more available from cooked veggies, for example, carrots, ketchup, and other processed tomato products.] c. “My doctor told me to eat less meat and more breads and cereals; now you are telling me that carbs raise my triglycerides. Can’t you health professionals talk to one another?” [One of my favorite responses was told to me by Connie DeLorme, PhD, RD, from Rochester, Minnesota: “We used to say that, but we have newer studies now and this is the most current advice I can give …”]

4. Why is the advice to get nutrients from food first given? [We are still learning about what constitutes an ideal diet.] There are circumstances when supplements are useful. Describe these circumstances. [See Table 18.16]

7. If you were developing a dietary supplement for older adults, what would you want in the formulation? Would you develop single-nutrient tablets or combinations? How would your formula be different than a formula for young adults? (LO 18.6)

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 18: Nutrition and older adults

8. Older adults want to stay independent and fit. You’re volunteering at a recreational center for older adults and Ms. Jones, who has arthritis, tells you that she has just been advised to lose weight in order to become more mobile. What are some questions you would want to ask her to support potential weight loss? Why might it be important to learn about her motivation? (LO 18.8)

9. Among U.S. adults ages 71 and older, 47.6% of men and 47.4% of women reportedly take supplements. What are some of the reasons for taking dietary supplements? Where do students get their own information about what to take? (LO 18.6)

10. Review the physical activity guidelines for older adults presented on page 474. Are they different than those for adults in general (Table 16.10)? When are old people too old to exercise? [Never—but Table 18.17 lists questions to ask before starting a new routine without a doctor’s approval.] What makes a good exercise routine for an older person? [Exercise needs to be individualized; one cannot generalize.] (LO 18.8)

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ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. Beliefs Related to Aging (LO 18.1) Total Time: 15 minutes What are some of the beliefs related to aging (including stereotypes) that students hold? Ask each student to take a minute or two to tell of their experience with an “old person.” When everyone has described their experience, reflect on what you, the instructor, heard. How old is “old”? 2. Physiological System Changes (LO 18.3) Total Time: 30 minutes Devise nutritional strategies to deal with each of the physiological system changes listed in Table 18.3. Assign a team for each system (photocopy Table 18.3 and cut it apart; the respiratory system can be skipped). Have each team member write down strategies to deal with each of the changes of aging in their assigned system. Then have the whole team compile the individual lists, clarifying their strategies so that everyone reaches agreement. Collect the team lists and compile them for the next class period, making a photocopy for each class member. 3. Oral Health and Nutrition (LO 18.3) Total Time: 30 minutes

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 18: Nutrition and older adults

Develop a short (half-page) piece on oral health and nutrition for a newsletter distributed at a community senior center. The audience consists of healthy older adults who generally have access to adequate dental care. Begin by identifying two nutritional habits that contribute to oral health. 4. Complete Worksheet 18-1: Case Stud—Assessment of the Nutritional Status of the Elderly (LO 18.1) Total Time: 20 minutes Answer Key: 1. From the available information, it appears that John has a score of at least 9 (high nutritional risk). 2. Financial difficulties, dental problems, unplanned weight loss in the past eight months, eating alone the majority of the time. 3. Tips for “What you can do” about tooth loss, economic hardship, reduced social contact, and involuntary weight loss. 4. Help John to find resources in his community that will help meet his nutrition and health care needs (e.g., dental services, meals on wheels, lunch and activities at the senior care center) and collaborate with other health care professionals (e.g., social worker) to help John access these programs.

5. Complete Worksheet 18.2: Estimate the Nutritional Requirements for the Elderly (LO 18.5) Total Time: 30 minutes Answer Key: 1. Males: [RMR = (10  wt) + (6.25  ht) – (5  age) + 5]  1.2 Males: [RMR = (10  66.4) + (6.25  180.3) – (5  78) + 5]  1.2 = 1687 calories 2. John’s current BMI is 20.4, which is near the low end of the healthy range. If he has not experienced any unintended weight loss recently and is not experiencing muscle wasting, then he should maintain his current weight. If anthropometry reveals muscle wasting, he might be encouraged to increase resistance exercise in conjunction with an adequate diet and potentially an increase in calorie intake to accrue muscle mass. 3. Using the RDA: 0.8 g/kg/day  66.4 kg = 53 g/day Using Rand’s recommendation: 0.83 g/kg/day  66.4 kg = 55 g/day (high quality) Using Morais and colleagues’ recommendation: 1.0–1.3 g/kg/day  66.4 kg = 66–86 g Suggestions: eat high-quality proteins (e.g., animal protein sources such as nonfat dairy foods, soy foods), be sure to consume adequate calories, and do resistance exercise to maintain protein stores.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 18: Nutrition and older adults

4. 1 mL fluid per calorie = 1687 mL fluid/day 5. Answers will vary but may include the following: include calcium sources in diet, include fruits and vegetables, look for ways to increase fiber intake (e.g., whole-grain breads), assess protein intake to ensure adequate intake from highquality sources, possibly add a daily multivitamin and mineral supplement.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 18: Nutrition and older adults

Worksheet 18-1: Case Study—Assessment of the Nutritional Status of the Elderly (LO 18.1)

John, 78 years old, is a veteran who is sometimes unhoused. He is missing many teeth from years of no dental care. John receives a monthly retirement check but has great difficulty meeting his monthly bills, let alone buying enough food, and this has caused many evictions. When he can afford them, John has his prescriptions filled for a diuretic (for high blood pressure) and a statin (for high cholesterol). John isn’t sure what his current weight is, but he has had to tighten his belt to the last notch over the past eight months. He has no family with whom he is still in contact, and he eats all of his meals alone. At a neighbor’s insistence, John is visiting the local senior center to eat lunch for the first time. The day he visits, each person is having a free nutrition screen completed by a program staff member. Questions: 1. Using the “Determine Your Nutritional Health” checklist (p. 459), assess John’s nutritional status. What is his score?

2. Review the “DETERMINE: Warning signs of poor nutritional health” checklist shown in Table 18.5 (p. 458). Prioritize John’s nutrition problems based on this screening tool.

3. What parts of the nutrition education handout created by the University of Florida IFAS Extension (access at http://edis.ifas.ufl.edu/he944) should be used to provide nutrition education to John?

4. What should the registered dietitian at the local senior center do for John to help address the nutrition problems you identified in #2?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 18: Nutrition and older adults

Worksheet 18.2: Estimate the Nutritional Requirements for the Elderly (LO 18.5) Directions: Use the information from Chapter 18 to complete this worksheet. 1. Determine the estimated calorie requirements (for weight maintenance) for John, a 78-year-old male who weighs 146 pounds, is 5 feet 11 inches, and is considered sedentary.

2. Does John need to gain or lose weight? How might this change his estimated calorie requirements?

3. Determine John’s estimated protein requirements. Also, John has difficulty chewing due to missing many teeth, so he avoids eating many types of meats. What suggestions do you have to help him consume an adequate amount of protein?

4. Determine John’s estimated fluid requirements.

5. John’s usual food intake is as follows: coffee, pastry, tuna salad on white bread, cola, potato chips, canned beans, hot dogs, coffee, and pie. What suggestions do you have to help him use dietary modifications to reduce his risk for chronic disease?

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Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 18: Nutrition and older adults

ADDITIONAL RESOURCES INTERNET RESOURCES •

General nutrition • DHHS Administration on Aging (resources for nutrition and a healthy lifestyle): http://www.aoa.gov • American Association of Retired Persons: http://www.aarp.org • CDC page with physical activity guidelines for older adults (including videos, examples, tips, and case profiles of active adults): http://www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html • Office of Disease Prevention and Health Promotion’s Physical Activity Guidelines for Americans: https://health.gov/paguidelines/second-edition/

•

Science of nutrition • Academy of Nutrition and Dietetics: http://www.eatright.org

•

Public food and nutrition programs • National Resource Center on Nutrition, Physical Activity and Aging: https://nutritionandaging.org

•

Nationwide priorities and nutritional health • Statistics—Centers for Disease Control and Prevention (Mortality and Morbidity Weekly Report): http://www.cdc.gov/mmwr • United States • Department of Agriculture, Center for Nutrition Policy and Promotion: http://www.cnpp.usda.gov • Environmental Protection Agency (Ground Water and Drinking Water): http://water.epa.gov/drink/index.cfm • Food and Drug Administration: http://www.fda.gov • National Center for Complementary and Integrative Health, National Institutes of Health: https://nccih.nih.gov • National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov/ • Oral Health in America (surgeon general’s report): https://www.nidcr.nih.gov/research/data-statistics/surgeon-general [return to top]

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

Instructor Manual

BROWN, NUTRITION THROUGH THE LIFE CYCLE, EIGHTH EDITION 2024, 978-035-773-0423; CHAPTER 19: NUTRITION AND OLDER ADULTS: CONDITIONS AND INTERVENTIONS

TABLE OF CONTENTS Purpose and Perspective of the Chapter ...........................................................................1 Chapter Objectives ..............................................................................................................1 Key Terms ........................................................................................................................... 2 What's New in This Chapter............................................................................................... 4 Chapter Outline ................................................................................................................... 5 Discussion Questions.......................................................................................................... 9 Additional Activities and Assignments ............................................................................ 10 Additional Resources ........................................................................................................ 16 Internet Resources.................................................................................................................. 16

PURPOSE AND PERSPECTIVE OF THE CHAPTER The purpose of this chapter is to highlight the fact that nutrition interventions can play a large role in older adults’ health. Aging adults have been shown to use proportionately more health care services and products than younger persons do. Aging adults want to stay healthy until death. Medical nutrition therapy (MNT) is a part of a comprehensive treatment plan that encourages health-promoting food choices when older adults are diagnosed with diseases.

CHAPTER OBJECTIVES The following objectives are addressed in this chapter: 19.1

Describe key nutritional approaches to the most prevalent chronic diseases of adults 65+, recognizing the heterogeneity of older populations.

19.2

Describe key nutritional approaches to heart disease in adults 65+, recognizing the heterogeneity of older populations.

19.3

Describe key nutritional approaches to addressing strokes and related diseases in adults 65+, recognizing the heterogeneity of older populations.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

19.4

Describe key nutritional approaches to hypertension in adults 65+, recognizing the heterogeneity of older populations.

19.5

Describe key nutritional approaches to diabetes in adults 65+, recognizing the heterogeneity of older populations.

19.6

Explain how sarcopenia combined with obesity affects fitness and weight management in older adults.

19.7

Describe key nutritional approaches to osteoporosis in adults 65+, recognizing the heterogeneity of older populations.

19.8

Identify three or more nutritional strategies that contribute to oral health.

19.9

Describe the three most common GI problems of older adults, along with nutritional management strategies to ameliorate each condition.

19.10 Describe key nutritional approaches to osteoarthritis in adults 65+, recognizing the heterogeneity of older populations. 19.11

Describe key nutritional approaches to cognitive impairment, dementia, and Alzheimer’s diseases of adults 65+, recognizing the heterogeneity of older populations.

19.12

Understand how comorbidities and polypharmacy increase nutritional risk in older adults.

19.13

Explain the challenges faced by underweight individuals and the consequences of sarcopenia on day-to-day functioning.

19.14 List three or more signs of dehydration and explain why maintaining hydration status is important for the health of an older person. 19.15

Explain how social support during bereavement can help the survivor to stay healthy.

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KEY TERMS Healthspan: Illness-free life span. Healthy: More than the absence of disease, health is a sense of well-being. Even individuals with a chronic condition may properly consider themselves to be healthy. For instance, a person with diabetes mellitus whose blood sugar is under control can be considered healthy.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

Quality of life: A measure of life satisfaction that is difficult to define, especially in an aging heterogeneous population. Quality-of-life measures include factors such as social contacts, economic security, and functional status. Medical nutrition therapy (MNT): Comprehensive nutrition services by registered dietitians to treat the nutritional aspects of acute and chronic diseases. Cerebrovascular disease: Conditions caused by problems that affect the blood supply to the brain. Transient ischemic attacks (TIAs): Temporary and insufficient blood supply to the brain. Aneurysm: Ballooning of the blood vessel wall. Aphasia: Difficulties in self-expression, including inability to speak, finding the right words, or understanding print or spoken words. Thrombus: Blood clot. Cerebral embolism: Piece of a blood clot formed elsewhere that travels to the brain. Carotid artery disease: Arteries that supply blood to the brain and neck becoming damaged. Atrial fibrillation: Degeneration of the heart muscle causing irregular contractions. Glycosylated hemoglobin A1c (HbA1c): A blood test that measures how well the blood sugar level has been maintained over the last 2 to 3 months. Sarcopenic obesity: Low lean body mass combined with excessive fat stores. Telopeptides: Molecules that degrade the major collagen of tendon and bone and leave carbon and nitrogen fragments in blood and urine. Xerostomia: Dry mouth can be a side effect of medications (especially antidepressants), of head and neck cancer treatments, of diabetes, and a symptom of Sjogren’s syndrome, which is an autoimmune disorder for which no cure is known. Gingiva: Gum tissue. Lower esophageal sphincter (LES): The muscle enabling closure of the junction between the esophagus and the stomach. Cobalamin: Another name for vitamin B12. Important roles of cobalamin are fatty-acid metabolism, synthesis of nucleic acid (i.e., DNA, a complex protein that controls the formation of healthy new cells), and formation of the myelin sheath that protects nerve cells. Homocysteine: Another intermediate product that depends on vitamin B12 for complete metabolism. However, both vitamin B12 and folate (another B vitamin) are

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

coenzymes in the breakdown of certain protein components in this pathway. Thus, elevated homocysteine levels can result from vitamin B12, folate, or pyridoxine deficiencies. Methylmalonic acid (MMA): An intermediate product that needs vitamin B12 as a coenzyme to complete the metabolic pathway for fatty-acid metabolism. Vitamin B12 is the only coenzyme in this reaction; when it is absent, the blood concentration of MMA rises. Diverticulitis: Infected “pockets” within the large intestine. Gluten: A protein found in wheat, spelt, kamut, dinkel, and triticale (genus Triticum), barley, and rye. Spelt, dinkel, and kamut are ancestral forms of today’s wheat. Oats appear on some “gluten” lists; oats are inherently gluten free, but they may be contaminated by gluten-containing grains during processing. Memory impairment: Moderate or severe impairment is when four or fewer words can be recalled from a list of 20. Mild cognitive impairment (MCI): Subtle loss of memory, thinking, and/or reasoning skills beyond expectations of normal but not serious enough to be classified as dementia. Adipocytokines: Adipose tissue secretes several signaling proteins, including the appetite suppressants adiponectin, leptin, and resistin. Antidiuretic hormone: Causes kidneys to absorb more water from urine, resulting in increased blood volume.

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WHAT'S NEW IN THIS CHAPTER The following elements are improvements in this chapter from the previous edition: • • • • • • • • •

Updated statistics in all sections and corresponding references Revised nutritional remedies for cardiovascular diseases section and updated American Heart Association (AHA) guidelines for cardiovascular disease Revised section on alcohol Revised section on diabetes nutrition interventions Updated expert consensus on bone health Updated definition of constipation Updated section on cognitive impairment, dementia, and Alzheimer’s disease Updated osteoarthritis risk factors and potential remedies Deleted Tables 19.3 and 19.16

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

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CHAPTER OUTLINE I.

Introduction a. Aging adults want to stay healthy and independent. b. Prevalence statistics are presented in Table 19.2 for heart disease, hypertension, stroke, cancer, and diabetes. c. When illness strikes, medical nutrition therapy aids recovery. d. Well-nourished patients heal faster and use fewer financial resources, prompting Medicare to make nutrition services available for reimbursement.

II. Nutrition and Health Describe key nutritional approaches to the most prevalent chronic diseases of adults 65+, recognizing the heterogeneity of older populations. (LO 19.1) a. The majority of older Americans have one or more chronic conditions. b. Old age is not a good reason to forgo health promotion. c. Good health habits contribute to delayed mortality and to higher functional status in old age. III. Heart Disease Describe key nutritional approaches to heart disease in adults 65+, recognizing the heterogeneity of older populations. (LO 19.2) a. Heart disease (cardiovascular disease, CVD) is the leading killer of older adults. b. Risk factors for the development of heart disease are the same for the elderly as for younger adults, although the risk factors have less predictive value as we age. c. Treatment factors for heart disease are provided in Table 19.3. IV. Stroke Describe key nutritional approaches to addressing strokes and related diseases in adults 65+, recognizing the heterogeneity of older populations. (LO 19.3) a. Stroke and TIAs are “serious conditions involving reduced cerebral blood flow.” b. Risk factors for stroke are provided; stroke is a leading cause of death among the elderly. V. Hypertension Describe key nutritional approaches to hypertension in adults 65+, recognizing the heterogeneity of older populations. (LO 19.4) a. Hypertension is defined as blood pressure reading greater than or equal to 140/90 mmHg.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

b. Only 34% of people living with hypertension are estimated to have it under control. c. The DASH diet (Table 19.3) is one of the nutritional remedies for blood pressure control; it is an excellent example of a balanced diet and of using a normal, wholesome diet to treat disease. VI. Diabetes: Special Concerns for Older Adults Describe key nutritional approaches to diabetes in adults 65+, recognizing the heterogeneity of older populations. (LO 19.5) a. Nearly 1 in 5 adults over age 65 have diabetes, primarily type 2 diabetes. b. Type 2 diabetes is the most common type of diabetes, and the most common risk factor is overweight combined with excess abdominal fat. c. Nutritional interventions, which should be individualized, are listed on pages 489–490. d. Native American and Mexican American populations tend to include complementary approaches in treatment. Remedies include evening primrose oil, milk thistle, fenugreek seeds, bitter melon, and prickly pear cactus (nopales). VII. Obesity Explain how sarcopenia combined with obesity affects fitness and weight management in older adults. (LO 19.6) a. Obesity rates decline in old age (Table 19.6). b. The BMI range least likely to be associated with mortality is 24.0–30.9. c. Researchers vary somewhat in their views of the BMI range that is considered health promoting in the elderly. Table 19.7 presents suggested “healthy” BMI ranges. d. Nutritional interventions for obesity in the elderly are discussed. VIII.

Osteoporosis Describe key nutritional approaches to osteoporosis in adults 65+, recognizing the heterogeneity of older populations. (LO 19.7)

a. b. c. d.

Typically thought of as a woman’s disease, osteoporosis also occurs in men. Table 19.8 lists risk factors associated with osteoporosis. Calcium is just one of the nutrients needed for bone mineralization. Lack of estrogen leads to bone loss, as do a sedentary lifestyle and extended bed rest. e. Adequate vitamin D, moderate sodium and caffeine intakes, and resistance exercise are recommended. IX. Oral Health

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

Identify three or more nutritional strategies that contribute to oral health. (LO 19.8) a. The prevalence of older adults who still have their natural teeth is increasing due to better dental care. b. Dry mouth or xerostomia can be a side effect of medications or disease. c. A compromised immune system increases the risk for periodontal disease. d. Recommendations for oral care in the elderly are the same as those for younger populations. X. Gastrointestinal Diseases Describe the three most common GI problems of older adults, along with nutritional management strategies to ameliorate each condition. (LO 19.9) a. The broad topic of GI diseases includes GERD, malabsorption, constipation, and diarrhea. b. Constipation is a major complaint of older adults (check out the shelf space allocated to fiber supplements in grocery stores near senior populations and compare this to a store catering to a young family clientele). c. Nutritional interventions for GERD are discussed. d. Vitamin B12 deficiency has dire consequences and is discussed here because inadequate B12 absorption is associated with old age (see Figure 19.3). e. Nutritional treatment for B12 deficiency includes intakes of B12 orally (crystalline or synthetic versions) or by injection. XI. Inflammatory Diseases: Osteoarthritis Describe key nutritional approaches to osteoarthritis in adults 65+, recognizing the heterogeneity of older populations. (LO 19.10) a. Arthritis is the most common form of inflammatory disease in older adults, and osteoarthritis occurs most frequently. b. Obesity and (possibly) a low intake of vitamin D increase the risk for developing osteoarthritis. c. Nutritional interventions for osteoarthritis, including chondroitin and glucosamine, are reviewed. XII. Cognitive Impairment, Dementia and Alzheimer’s Disease Describe key nutritional approaches to cognitive impairment, dementia, and Alzheimer’s diseases of adults 65+, recognizing the heterogeneity of older populations. (LO 19.11) a. Alzheimer’s disease is the most prevalent cause of dementia, and is the fifth leading cause of death for adults age 65 years and older in the United States.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

b. Motivation and memory are necessary for an individual to plan, prepare, and eat meals. c. When impairment is severe enough that an individual forgets to eat or eats unsafe foods, assistance is needed to prevent weight loss and malnutrition. d. Food safety practices may slip when energy, eyesight, and memory decline. e. Nutritional interventions to avoid unplanned weight loss are often needed. f. Adaptive eating utensils are available to assist with adequate food intake. XIII.

Polypharmacy: Prescription and Over-the-Counter Medications Understand how comorbidities and polypharmacy increase nutritional risk in older adults. (LO 19.12)

a. Polypharmacy is common among the elderly. b. Table 19.13 provides the vitamin K content of selected fruits and vegetables (a concern for people taking warfarin). c. Table 19.14 lists medications associated with chronic conditions common in older adults and their nutrition implications. XIV.

Low Body Weight/Unintentional Weight Loss Explain the challenges faced by underweight individuals and the consequences of sarcopenia on day-to-day functioning. (LO 19.13)

a. A significant problem for resiliency in older adults is underweight, undesired weight loss, and thinness (BMI under 18.5 according to NHLBI guidelines, or under 18.5 in three grades of thinness according to the WHO). b. Examining an elderly person’s weight history can offer insight into their health status. c. Treatment for underweight involves consideration of calorie, protein, and fluid needs. XV. Dehydration List three or more signs of dehydration and explain why maintaining hydration status is important for the health of an older person. (LO 19.14) a. Seven indicators of dehydration are listed on p. 508. b. Declining thirst acuity and kidney function coupled with swallowing problems, incontinence, depression, and dementia can contribute to dehydration. c. “I don’t want to have to go to the bathroom” is a common reason for not drinking more fluids. d. Encouraging nutrient-dense fluids may help to reframe the problem. e. Dehydration at the end of life is a separate issue that could be addressed as part of an ethics discussion. XVI.

Bereavement

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

Explain how social support during bereavement can help the survivor to stay healthy. (LO 19.15) a. Grieving for losses, especially after the loss of a significant other, diverts attention from normal activities. b. Mourning leaves people vulnerable to malnutrition. [return to top]

DISCUSSION QUESTIONS You can assign these questions several ways: in a discussion forum in your LMS; as whole-class discussions in person; or as a partner or group activity in class. 1. What are the leading chronic conditions in older adults, and for each of the three leading conditions, what are the nutritional implications? [Per Table 19.2, the top three are heart disease, cancer, and stroke.] (LO 19.1) 2. The DASH diet to decrease blood pressure relies on a combination of food components. What is recommended in the DASH pattern of eating? How is this similar to the eating plans available from ChooseMyPlate.gov? How do the recommended portions of fruits and vegetables compare (Table 19.3 describes DASH portion sizes)? (LO 19.4)

3. Whole grains are emphasized in the DASH diet. Bring labels of grain products, including some whole-grain foods, and have students examine the ingredient lists and fiber content. Ask them to identify the whole-grain products. How difficult would this be for the average shopper? (LO 19.4)

4. What advice is not given as part of the DASH diet in Table 19.3? [It does not address alcohol, which is implicated in hypertension, or sodium, for which lower intakes are linked to greater reductions in blood pressure.] (LO 19.4) 5. Discuss the suspected etiology of insulin resistance/metabolic syndrome. What nutrition advice would you give to an obese person who has a family history of heart disease? Discuss the pros and cons of a high-carbohydrate, low-fat approach and of a moderate-carbohydrate, higher-protein approach to managing insulin resistance. What might be a typical lunch and snack recommendation? (LO 19.5) 6. Part of oral health status is determined “during critical periods of growth and development.” Are there nutritional interventions an older adult can practice to

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

promote oral health? How would you advise your grandparent who knows that you are studying nutrition? (LO 19.8) 7. In the United States, where overweight and obesity are a growing problem, underweight is less commonly discussed. For instance, the Appendix includes several pictures of overweight bodies, but few of thin persons. Ask students to take a position on this statement: “In older populations, underweight or weight loss is a greater problem than obesity” and have them discuss their reasons for taking that position. [For example, weight loss can indicate loss of lean body mass, leading to declining strength and a greater potential for falls.] (LO 19.6 & 19.13) [return to top]

ADDITIONAL ACTIVITIES AND ASSIGNMENTS 1. Class Case Study (LO 19.13) Total Time: 25 minutes Use Case Study 19.2 on page 507: Class plays role of the RD. Assign small teams (2–4) to deal with the first three questions. Select teams at random and have them report on how they dealt with one of the questions; go around the room until every group has reported or contributed ideas about the care of Ms. Dawson. [The instructor can summarize the points made and reflect on how the class dealt with the issues.] Use question #4 to ask the whole class to generate other information that would be helpful in counseling. [This activity is a chance to bring in favorite screening or assessment tools to see how these tools can be applied to gather information needed to do nutrition intervention; validation and reliability can be discussed, as well.] 2. Reducing the Risk of Osteoporosis (LO 19.7) Total Time: 30 minutes Men and women are differentially prone to osteoporosis (the prevalence is 4 women to 1 man). Your community is having a health fair, and a reporter wants to talk with you about nutritional interventions for osteoporosis. Consider how a risk reduction and a treatment approach to osteoporosis might differ. Prepare three talking points for a media interview (have students choose print, radio, or TV). What are three or four questions an interviewer might ask you? (For example, “Does it really matter if I get enough calcium every day?” “What recommendations would you make about coffee consumption?”) How will you respond to those questions? How might you help the audience picture what you think is important? [Class facilitator could ask a few students to role-play a reporter, and the interviewee should be able to discuss and evaluate the talking points generated.] 3. Underweight and Weight Loss in Older Adults (LO 19.13) Total Time: Will vary Wide-ranging discussions associate underweight or weight loss with older adults who have dentures. Complete a National Library of Medicine/PubMed search (https://www.ncbi.nlm.nih.gov/pubmed/) on this topic and choose one article to

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

read and evaluate. (Have the class determine the chronological definition of “elderly.”) Have each student summarize the study (e.g., type of study, number of subjects, weight changes monitored). Encourage the evaluation of articles from dental, dietetics, and medical journals. 4. Complete Worksheet 10-1: Case Study—Nutrition Intervention in Alzheimer’s Disease (LO 19.11) Total Time: 30 minutes Answer Key: 1. Answers will vary but might include “Medical nutrition therapy must balance medical needs and individual desires and maintain quality of life.” Basically, the benefit of the diet must fit within the context of the quality of life in a case-bycase assessment. 2. Probably not, as she is refusing most meals and fluids; the nursing home staff need additional options for providing nourishment to Ruth at this time. They can manage her blood sugars with medication as needed. 3. High-calorie supplements, a calm dining environment, serving finger foods, and mealtime supervision to provide verbal and visual cues. 4. Answers will vary but might include “Registered dietitians should work collaboratively to make nutrition, hydration, and feeding recommendations in individual cases. Registered dietitians have an active role in determining the nutrition and hydration requirements for individuals throughout the life span.”

5. Completed Worksheet 19-2: Warfarin and Vitamin K Intake (LO 19.12) Total Time: 30 minutes Answer Key: 1. Food or Beverage Item

Serving Size

Vitamin K (g)

Day #1 Oatmeal

1 cup

1.2

Whole milk

1 cup

0.5

Orange juice

½ cup

0.1

Tuna salad

½ cup

21.2

Wheat bread

2 slices

1.1

Baby carrots

21.1

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

Food or Beverage Item

Serving Size

Vitamin K (g)

Roast beef

4 ounces

1.9

Baked potato w/ peel

1 medium

3.5

Butter

2 tsp

0.7

Sour cream

1 Tbsp

0.3

Tomatoes, fresh

½ cup

7.1

Applesauce

1 cup

1.5 Daily Total: 60.2

Day #2 Special K

1 cup

0.2

Whole milk

1 cup

0.5

Orange juice

1 cup

0.2

Roast beef

3 ounces

1.4

Wheat bread

2 slices

1.1

Salad greens

1 cup

111.5

Italian dressing

2 Tbsp

16.5

Baked chicken

4 ounces

2.7

Spinach, cooked

½ cup

554

White rice

1 cup

Grapes

½ cup

11.7 Daily Total: 699.8

2. Day 1, no. Day 2, he greatly exceeded it. 3. The most important nutritional consideration while on warfarin is to have a stable vitamin K intake, not to avoid vitamin K intake altogether. His vitamin K intake between the two days varied greatly. And he should probably avoid spinach. 4. Answers will vary.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

Worksheet 10-1: Case Study—Nutrition Intervention in Alzheimer’s Disease (LO 19.11) Ruth, 82 years old, was placed in a nursing home due to her family’s inability to meet her increasing health care needs in the late stages of Alzheimer’s disease. This was a very difficult decision for the family, especially for her husband, 85year-old Dale. Ruth had been on a diet for diabetes at home, but now is refusing almost all meals and fluids. Her family has been asked to decide on their plan for the provision of tube feeding and IV fluids should this become necessary. In the meantime, the dietary department is doing their best to offer foods to Ruth that she used to like, within the guidelines of a diet for diabetes. Ruth is completely unable to feed herself with utensils, and she gets agitated when placed in the dining room with the other residents. She has been losing weight over the past two months since her admission.

Questions: 1. What is the therapeutic benefit of a diet (e.g., for diabetes) when an elderly person is in long-term care?

2. Should Ruth be required to follow a diet for diabetes at this time?

3. What nutrition interventions might be helpful for Ruth at this time?

4. What are the ethical considerations dietetics professionals face related to providing nutrition and hydration at the end of someone’s life?

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

Worksheet 19-2: Warfarin and Vitamin K Intake (LO 19.12) Directions: Use the information in Table 19.14 and the “What’s in the Foods You Eat” search tool (https://reedir.arsnet.usda.gov/codesearchwebapp/(S(wd5wmbccs5pu2001d0pcz 1u4))/CodeSearch.aspx) to complete this worksheet.

1. Listed below is the 48-hour recall for a 72-year-old male who is new to using warfarin. Complete this table with the vitamin K content of his foods. Food or Beverage Item

Serving Size

Vitamin K (g)

Day #1 Oatmeal

1 cup

Whole milk

1 cup

Orange juice

½ cup

Tuna salad

½ cup

Wheat bread

2 slices

Baby carrots

Roast beef

4 ounces

Baked potato w/ peel

1 medium

Butter

2 tsp

Sour cream

1 Tbsp

Tomatoes, fresh

½ cup

Applesauce

1 cup Daily Total:

Day #2 Special K®

1 cup

Whole milk

1 cup

Orange juice

1 cup

Roast beef

3 ounces

Wheat bread

2 slices

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

Salad greens

1 cup

Italian dressing

2 Tbsp

Baked chicken

4 ounces

Spinach, cooked

½ cup

White rice

1 cup

Grapes

½ cup Daily Total:

2. Is he meeting his DRI for vitamin K?

3. What advice do you have for him regarding his vitamin K intake over these two days?

4. Search the internet for patient education materials on warfarin and vitamin K intake. Are the messages to the patient consistent? Confusing? How do you know the advice is reputable? Summarize what you found.

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

ADDITIONAL RESOURCES INTERNET RESOURCES •

General nutrition • Center for Medicare and Medicaid Services: http://www.cms.hhs.gov • Malnutrition Universal Screening Tool (MUST): http://www.bapen.org.uk • World Health Organization Fracture Risk Assessment Tool (FRAX®): https://www.shef.ac.uk/FRAX/tool.jsp • Consumer Lab: http://www.consumerlab.com

Additional sites •

Elderly nutrition: conditions and interventions • American Diabetes Association: http://www.diabetes.org • National Institute on Aging Alzheimer’s Disease Education and Referral Center: http://www.nia.nih.gov/alzheimers • Academy of Nutrition and Dietetics: http://www.eatright.org • National Osteoporosis Foundation: http://www.nof.org • Caring Connections (National Hospice and Palliative Care Organization): http://www.caringinfo.org/ • American Institute for Cancer Research (1-800-843-8114): http://www.aicr.org • National Dairy Council: http://www.nationaldairycouncil.org/HEALTHANDWELLNESS/DAIRYSHEALTH BENEFITS/Pages/BoneHealth.aspx • Fight Bac! Partnership for Food Safety Education: http://www.fightbac.org/

•

Public food and nutrition programs • Food Safety for Seniors—Food and Drug Administration and Center for Food Safety and Applied Nutrition: https://www.fda.gov/Food/FoodborneIllnessContaminants/PeopleAtRisk/ucm 2006970.htm

•

Nationwide priorities and nutritional health • United States • National Center for Complementary and Integrative Health, National Institutes of Health: https://nccih.nih.gov • National Institute of Diabetes and Digestive and Kidney Diseases: http://www2.niddk.nih.gov/

Instructor Manual: Brown, Nutrition Through the Life Cycle, Eighth Edition 2024, 978-035-773-0423; Chapter 19: Nutrition and Older Adults: Conditions and Interventions

•

National Institutes of Health, Office of Dietary Supplements: http://ods.od.nih.gov/ • National Institute of Mental Health: http://www.nimh.nih.gov [return to top]