Nutrition in Life cycle.pdf

Nutrition in Life cycle.pdf

1. School of the Public Health
Department of epidemiology & Biostatistics

Nutrition in the life cycle



Dr. Haji Aman (PhD, Ass. Professor in Human Nutrition)


December,2022
AHMC
Adama

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 12/26/2023

2. Course contents
•
•
•
•
•
Introduction to Nutrition in the lifecycle
Maternal nutrition and Reproduction
Lactation and Breastfeeding
Infant and Young Child Feeding
Adolescent, adult, and elderly nutrition





2Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

3. References
•
•
•
•
Gibney, Michael J. Public health nutrition. 4 edt : Oxford, UK : Blackwell
Science, 2004
Finkelstein, Julia L.; Mehta, Saurabh. Nutrition and HIV : epidemiological
evidence to public health. CRC Press; 2018
Buttriss, Judith; Kearney, John M.; Lanham-New, Susan; Welch, Ailsa.
Public health nutrition. John Wiley & Sons; 2018
Sheila Vir. Public Health Nutrition in Developing Countries. Woodhead
Publishing; 2011

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 32/26/2023

4. Nutrition in the Life cycle
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 42/26/2023

5. Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 52/26/2023

6. Main stages of human life cycle
Dr. Haji
Aman(
6
6
2/26/2023

7. The four phases of human Growth
•
•
•
•
Phase1(Intra Uterine period)
Phase 2 (Infancy)
Phase 3 (Childhood)
Phase 4 (Adolescence)
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
7
2/26/2023

8.
Nutrition in the life cycle


Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 8
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
A powerful framework for understanding the vulnerabilities
and opportunities for investing at critical periods.
These sensitive periods also represent windows of
opportunity through interventions in a range of sectors
2/26/2023

9. Nutrition in the life cycle-different stages
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 92/26/2023

10. Why Nutrition in lifecycle?
•
•
•
•
Reduction in infant & child mortality, but surviving children
are not healthy
Relative decrease in rate of malnutrition, but the absolute
numbers of children are increasing every year in millions
The prevalence of LBW is increasing & no significant
improvement has been made since 1970’s
Many years after Safe Motherhood Initiative (1987)
maternal mortality is still high in LIC due to pregnancy
related complication

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 102/26/2023

11. Why….?
•
•
Maximum benefits in one age group come from
investments in an earlier age group (there is a cumulative
effect in the next generation)
Health & nutrition programs implemented well before
women become pregnant, & within a life-cycle perspective,
have long term impacts on succeeding generations.


Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 112/26/2023

12. What is the catch up rate for
foetus/Children with IUGR at the later life?
2/26/2023 Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 12

13. Why nutrition…
•
•
•
•
•
Undernutrition often starts in-utero due to maternal
undernutrition & extend throughout the life cycle
A foetus w/IUGR is unlikely to catch up at the later life
Most growth failure occurs from before birth until 2-3
years of age
A child who is stunted at three years of age is likely to
remain stunted throughout life
Micronutrient deficiencies during pregnancy have serious
implications for the developing foetus


Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 132/26/2023

14. 
1.
2.
3.
4.
5.
Women in LIC-more vulnerable to malnutrition
Serious physiological depletion & sometimes to overt
malnutrition-"maternal depletion syndrome‘’ dueto ;
Born malnourished
Poor health
Heavy burden of reproductive activities
Heavy work load
Low intake
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 142/26/2023
Why nutrition…

15. Maternal Depletion :% spent on child bearing &
nurturing
Variables Industrial
Countries
Developing
countries
Menarche,age
Menopause,age
Fertile periods, years
11
53
42
14
42
28
Number of children
Months pregnant
Months lactating
2
2x9=18
2x24=48
6
6x9=54
6x24=144
Months reproducing
*Total
*As percent of fertile
period

66 mo.

13%

198mo.

59%
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 152/26/2023

16. Intergenerational link of malnutrition (UN-ACC/SCN
2000)
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 162/26/2023

17. The “window of opportunity” for improving nutrition is
very small... Pre-pregnancy until 18-24 months of age
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 172/26/2023

18. Preconception Nutrition
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 182/26/2023

19. Preconception overview-infertility
Dr. Haji
Aman(
19
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~15% of all couples in the Western world are involuntarily
childless (5% in Ethiopia , 2005).
~ 40% of couples diagnosed as infertile will conceive a
child in 3 years without the help of technology
Healthy couples have a 30–50% chance of a diagnosed
pregnancy within a given menstrual cycle
2/26/2023

20. Subfertility
Dr. Haji Aman( PhD, Asst.
Professor in Human Nutrition
20
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It is reduced level of fertility characterized by unusually
long time for conception
~18% of couples experience subfertililty(US)
Examples:
Having multiple miscarriages
Sperm abnormalities
Infrequent ovulation
2/26/2023

21. Nutrition related disruption of fertility
Dr. Haji Aman( PhD, Asst. Professor in
Human Nutrition 21
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Undernutrition
Weight loss
Obesity
High exercise levels
Intake of specific foods and food
components
2/26/2023

22. Dr. Haji Aman( PhD, Asst. Professor
in Human Nutrition 22
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

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Chronic undernutrition
Primary effect: birth of small & frail infants with
high likelihood of death in the first year of life
Acute undernutrition
Associated with a dramatic decline in fertility that
recovers when food intake resumes
2/26/2023

23. What happens if a woman loss >10-15% of usual
weight?

2/26/2023 Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 23

24. Weight loss and fertility in females
Dr. Haji
Aman(
24
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>10-15% of usual weight decreases estrogen
Results in amenorrhea
Anovulatory cycles,
Short or absent luteal phases
Treatment with fertility drug Clomid (clomiphene)
not effective in underweight women
2/26/2023

25. Body fat and fertility
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition
25
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Decreased fertility seen with low or high body fat due to
alterations in hormones
Estrogen & leptin
Leptin is a satiety hormone
Levels increased with high body fat & reduced
with low body fat
Both extremes lower fertility
Infertility lower with BMI <20 or >30 kg/m
2
2/26/2023

26. Overweight and fertility in males
Dr. Haji
Aman(
26
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Obesity and insulin resistance are a cause of infertility
interfere with the normal secretion and transport of
androgens
As androgens are activators of lipolysis, further
adiposity is stimulated by impaired action of the
androgens
2/26/2023

27. The relationship between male obesity
and
subfertility
Dr. Haji
Aman(
272/26/2023

28. Exercise and infertility
Dr. Haji Aman( PhD, Asst. Professor in
HumanNutrition
28
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Adverse effects of intense physical activity
Delayed age at puberty
Lack menstrual cycles
Appear to be related to hormonal and metabolic
changes
Related to caloric deficits
Reduced levels of estrogen
Low levels of body fat
2/26/2023

29. What is the relationship between caffeine and
fertility?
2/26/2023 Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 29

30. Caffeine and fertility


•
•
Caffeine appears to prolong time to conception
Daily caffeine intake & reduction in conception :
>300 mg/d results in ~27%
>500 mg/d (>4 cups of coffee) results in ~50%
30

30
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

31. Special concerns of younger or older
mothers-to-be
Dr. Haji
Aman(
31
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Teenage mothers
Still growing, more likely to have an unbalanced diet
More likely to develop pregnancy-induced
hypertension, iron-deficiency anemia, and deliver
premature babies
Older mothers
Higher risk for complications including gestational
diabetes and pregnancy-induced hypertension
Babies are more likely to have Down syndrome or
other developmental disabilities
2/26/2023

32. Preparation for pregnancy
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
35

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Avoid cigarettes, alcohol, and illicit drugs
Smoking increases the risk of infertility, a low birth
weight baby, stunted growth or intellectual development,
and sudden infant death syndrome (SIDS)
Drinking alcohol during pregnancy can lead to fetal
alcohol spectrum disorders (FASD): pregnant women are
advised to abstain completely from alcohol
2/26/2023

33. Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 332/26/2023

34. Preparation for pregnancy
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
36


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Managing chronic conditions:
Diabetes, hypertension, PKU or sexually transmitted
disease can increase maternal and fetal
complications if not controlled before conception
Medications may be contraindicated during
pregnancy, so pre-pregnancy counseling is essential
2/26/2023

35. Preparation for pregnancy
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 37
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Dietary preparation
Increased intake of folate
Reducing exposure to high dose of vitamin A
2/26/2023

36. Vitamin A exposure
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
38
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An essential nutrient but intake should be restricted during
pregnancy
Its teratogenic effect was first seen in animal studies
The evidence in humans is based on adverse effects after
exposure to pharmacological agents (in the form of 12-cis-
retinoic acid)
Craniofacial, heart defects and central nervous system
abnormalities
There are few recorded cases of such effect with dietary
exposure
2/26/2023

37. Folic acid defieciencies
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 372/26/2023

38. Nutrition during
pregnancy
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition
382/26/2023

39. Is pregnancy physiological and pathological?
2/26/2023 Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 39

40. Introduction
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin




Pregnancy is considered physiological if mothers:
Produce a healthy baby with appropriate weight at birth
(in healthy, well nourished communities the incidence
of LBW is less than 6%)
Produce enough milk (>750g in the first 6 months) of
good quality (70 kcal and 1.2g protein per 100g) which
is sufficient for the growth of exclusively breast fed
infants during the first 6 months
Mothers’ nutritional status is not depleted
402/26/2023

41. What is the acceptable weight gain during
pregnancy ?
2/26/2023 Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 41

42. Introduction
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
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A well nourished woman before pregnancy gains about
20% of her pre-pregnant weight during pregnancy
Weight gain during pregnancy follows a different curve
than fetal growth
First two trimesters are anabolic (growth of breasts,
uterus/placenta production of amniotic fluid, increased in
blood volume and deposition of body fat). This time the
fetal growth is slow
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
422/26/2023

43. Introduction
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
DPFH18/04/201
6
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
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A tripling of weight between 28 and 40 weeks from about
1000g to 3200-3600
Mother subsidizes fetal growth (uses fat stores) if her
intake is not sufficient -she will loose weight
The last trimester is the most vulnerable period for
the fetus in terms of birth weight
432/26/2023

44. Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
442/26/2023

45. Recommended weight gain during pregnancy based on
pre-regnancy weight
Source: IOM, 2009
DPFH18/04/201
6
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
452/26/2023

46. The components of maternal weight
gain during pregnancy
DPFH18/04/201
6
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
462/26/2023

47. Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
472/26/2023

48. Nutrition in foetal developments
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

•
Foetal development

Maximum increase-length-at 20-30 weeks of gestation;
weight-during 3
rd
trimester

Only 1% of foetal body weight is fat at 26 wks compared
to 12% at 38 weeks

The timing of undernutrition-different effects on weight &
length
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 482/26/2023

49. Low Birth Weight-Consequences
•

•
•
•
Increased Mortality & Morbidity
Risk of mortality
BW 2,000-2,499g:3,000- 3,499 g=10:1

IUGR & LBW-more susceptible to hypoglycaemia & to
birth asphyxia

Stunted higher risk than wasted

Risk increase with-severe GR; LBW due to preterm
delivery; Preterm + LBW

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 492/26/2023

50. What is the rate of catch up after stunting?
2/26/2023 Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 50

51. Greater Risk of Stunting/child growth
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•
•
•
•

Nutritional status of pregnant women greater than postnatal
factors

Stunting which starts in utero becomes worse if the diet or
health status is inadequate during postnatal development

A review of 12 studies-IUGR-term underwent partial catch-up
growth during their first two years of life

Wasted demonstrate better postpartum weight catch-up

Stunted tend not to catch up


Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 512/26/2023

52. Poor Neurodevelopmental Outcomes

•
•
•
•

LBW-more likely to experience developmental deficits

Undernutrition before 26 wks of GA has a greater impact

A study showed association b/n IUGR & cognitive
development & behaviour in the first six years of life

Concluded that deficits in performance of the IUGR group
began to appear between 1 & 2 years of age
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 522/26/2023

53. •
•

IUGR-serious adverse impact on later work productivity &
income generating potential

Guatemala longitudinal study- males & females born IUGR
performed significantly more poorly on tests of strength at
15 yrs of age

Reduced Strength & Work Capacity
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 532/26/2023

54. What is critical periods during fetal development?
•
•
•
•
Times of intense development and rapid cell division are
called critical periods
Critical in the sense that those cellular activities can
occur only at those times.

If cell division and number are limited during a critical
period, fully recovery is not possible.

The development of each organ and tissue is most
vulnerable to adverse influence (such as nutrient
deficiencies and toxins) during its own critical period.

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 542/26/2023

55. Critical Periods of Development



During embryonic development (from 2 to 8 weeks), many
of the tissues are in their critical periods (purple area of the
bars); events occur that will have irreversible effects on the
development of those tissues.
In the later stages of development (green area of the bars),
the tissues continue to grow and change, but the events are
less critical in that they are relatively minor or reversible.
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
552/26/2023

56. Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
562/26/2023

57. Concept of metabolic programming
•
•
The fetus makes adaptations as a result of these
unfavorable metabolic conditions in the maternal
surroundings and if this takes place within a critical
timeframe, it leads to a permanent change in the child’s
metabolism (programming).
This phenomenon goes by many names; it is called early
life programming or metabolic, perinatal or early
programming, foetal origin of adult hood diseases.


Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 572/26/2023

58. •
•
•
•
•
Size, wasting & stunting at birth associated with risk of
chronic diseases-hypertension, coronary heart disease,
stroke & type-2 diabetes
Theories to explain the link:
Barker’s theory ( risk of FOAD)
Malnutrition at the critical periods of intra uterine
life
“Thrifty genotype” hypothesis: The concept of 'foetal
programming’ (certain populations may have genes
that determine increased fat storage,)
Increased Risk of Chronic Diseases
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 582/26/2023

59. Fetal nourishment
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
•
•
•
Weeks 2–5: embryo receives nourishment from uterine lining
After week 5 until birth: developing baby receives
nourishment from placenta
Placenta: an organ produced from maternal and embryonic
tissues
Secretes hormones
Transfers nutrients and oxygen from the mother’s
blood to the fetus, removes metabolic wastes
Transport via umbilical cord
592/26/2023

60. Fetal nourishment
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
DPFH18/04/201
6

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
Placenta :
Prevents passage of red blood cells, bacteria,
and many large proteins from mother to fetus
Alcohol, drugs, and other potentially harmful
substances can cross the placenta
602/26/2023

61. Total energy and macronutrients need during
pregnancy

•
•
•
It is often said that a pregnant woman is “eating for two.”
Although this is technically correct, mothers-to-be often
overestimate their need for additional calories, especially
early in the pregnancy.
Energy requirements are generally the same as non-pregnant
women in the first trimester and then increase in the second
trimester, estimated at 340 kcal and 452 kcal per day in the
second and third trimesters, respectively. 1 additional meals
per day

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 612/26/2023

62. Total energy
•
•
•
Protein; the amount of protein required during the first half
of pregnancy is the same as that for non-pregnant women,
0.8–1.0 g/kg per day or 10–15% of the energy required
and that during the second half of the pregnancy is 1.1
g/kg per day.

A woman who avoids animal source foods for various
reasons may not consume dairy products like, meat, fish,
or poultry, placing her at high risk for protein deficiency
both before and during pregnancy.
Therefore, she need to compensate by consuming
essential amino acids from plant sources.

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 622/26/2023

63. Total energy …
•
•
Lipids; Lipids (fats/oils) are source of concentrated calories
and may be beneficial to women at risk of energy
malnutrition while pregnant.

There is no separate reference for fat intake during
pregnancy and the recommendation remains 20% to 35% of
total calories, the same as for the general population/non-
pregnant women.

Omega-3 fatty acids are critical for fetal brain development
and have been associated with improved vision in preterm
infants, as well as better cardiovascular health later in life.
the richest source of omega-3 is seafood and could also be
obtained from fish oil.

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 632/26/2023

64. Total energy …
•
•
•
Carbohydrate; Dietary carbohydrate is broken down to form
glucose, also known as blood sugar. The rapid growth of the
fetus requires that ample amounts of energy in the form of
glucose be available to the fetus at all times. Carbohydrates
should comprise 45-64% of daily calories.

Fibers; AI of total fiber for pregnant women is 28g/day and
for lactation 29g/day.
A high quantity of fiber in the diet slows gastric emptying
time and results in a significant reduction in postprandial
blood glucose and insulin levels. Fiber also is effective for
relief of constipation along with adequate fluid intake.


Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 642/26/2023

65. •
•
Fluids; A benchmark for the total amount of water
recommended to be consumed from food and water for 19
to 50 year olds is 35ml per kilogram of body weight per day
and this recommendation stands for pregnant women as
well.
Hence, fluid intake should not be less than 1.5 liters of
water per day.




Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 652/26/2023

66. Micronutrients need during pregnancy
•
•
Micronutrient supplementation during pregnancy and
lactation shows the dosage and timing for vitamin A, iron-
folate, and iodine supplementation.

Appropriate regimens for micronutrient supplementation
vary with the prevalence and epidemiology of deficiencies
and with existing policies and programs.

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 662/26/2023

67. Daily iron requirements and daily dietary iron
absorption in pregnancy
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
672/26/2023

68. Activity during the second trimester
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
DPFH18/04/201
6
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
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30 minutes or more of moderate exercise on most days is
recommended
Low-impact activities pose less risk for
injury to mother or baby
Must take care to avoid significant increases in body core
temperature and drink plenty of fluids to avoid
dehydration
682/26/2023

69. Exercise Guidelines during Pregnancy
o



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



Do
drink water before , after, and during exercise.
warm up with 5 to 10 minutes of light activity.
30 minutes or more of moderate physical activity ; 20 to
60 minutes of more intense activity on 3 to 5 days a
week will provide greater benefits.
cool down with 5 to 10 minutes of slow activity and
gentle stretching
begin to exercise gradually.
exercise regularly (most , if not all days of the week).
eat enough to support the needs of pregnancy plus
exercise.
rest adequately.
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
692/26/2023

70. DON'T

o
o
o
o
o
o
exercise while lying on your back after the first trimester
of pregnancy or stand motionless for prolonged periods.
exercise vigorously after long periods of inactivity.
exercise in hot , humid weather.
exercise when sick with fever.
exercise if you experience any pain , discomfort , or fatigue.
participate in activities that may harm the abdomen or
involve jerky, bouncy movements.
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
702/26/2023

71. •
•
•
Hygiene Behaviours:

Practice hand washing
Correct disposal of wastes
Use of footwear

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 712/26/2023

72. Nutrition problems during the first trimester
DPFH 1918/04/201
6
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

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
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Nausea and vomiting of pregnancy (NVP):
Begins during the first trimester and often ends by the
20
th
week of pregnancy
Cause is unknown, but estrogen and progesterone are
thought to play a role
Correlations have been shown between hCG
concentrations
and the severity of NVP
Vitamin B6 may reduce nausea and vomiting
In rare cases, women experience hyperemesis
gravadarum, severe vomiting which can lead to
dehydration, electrolyte imbalances, weight loss and may
require hospitalization
Small, frequent meals, avoiding an empty stomach, high
carbohydrate foods, ginger, and salty foods combined
with sour beverages help manage nausea
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
722/26/2023

73. The temporal association between symptoms of nausea and vomiting
in pregnancy and concentrations of hCG.
DPFH 2018/04/201
6
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
732/26/2023

74. Nutrition Problems during the first trimester
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin





Cravings and aversions:
Aversions are rejecting foods or beverages that might
have been staples prior to pregnancy
Food cravings are strong desires to consume particular
food items
Unknown cause, possibly hormonal or physiological (for
example, taste and smell changes), psychological, or
behavioral changes
Women suffering from NVP are more likely to report
food aversions and craving than those who do not
742/26/2023

75. Nutrition during the first trimester
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
DPFH18/04/201
6





Craving and aversions
Common cravings
Carbohydrate foods, sweets, candy, fruit,
fish, etc
Common aversions
Coffee, highly seasoned foods, fried foods
752/26/2023

76. Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
762/26/2023

77. Nutrition during the first trimester






Pica
Abnormal, compulsive intake of substances that have no
nutritional value
e.g. Consumption of clay or soil (geophagia), or ice
(pagophagia) dirt, paint chips, soap, chalk etc,
Can be associated with mental illness and some
micronutrient deficiencies ( iron, zinc); stress, anxiety
Most commonly associated with women of low
socioeconomic status
Pica could introduce toxins and ingestion of clay could lead
to decreased absorption of iron, Zinc or copper
18/04/2018
23
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 772/26/2023

78. Complications during the second
trimester
DPFH18/04/201
6




Potential complications: gestational diabetes and
hypertension
Gestational diabetes occurs when a woman develops high
blood glucose levels during her pregnancy
May result in macrosomia, jaundice, breathing problems,
birth defects, or hypoglycemia after birth
Eating healthfully, maintaining a healthy weight,
and exercising regularly can reduce risk
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
782/26/2023

79. Caffeine consumption
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
DPFH18/04/201
6



Can be taken in the form of coffee, tea, soft drinks, energy
drinks, etc
Most of the studies already conducted suggest an
association of increased (>100mg/d) caffeine consumption
and miscarriage
There are some strong criticism about the design and
analysis used
792/26/2023

80. Teenage pregnancy
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin



Nutrient intake must meet their needs for growth and for
pregnancy
Increased risk of hypertensive disorders of pregnancy and
delivering preterm and low- birth-weight babies
May stop growing themselves
802/26/2023

81. Teenage pregnancy
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
•
•
Nutrient needs of pregnant teens
differ from those of pregnant adults
The percentage increase in
micronutrient needs above non-
pregnant levels is shown for 14- to
18-year-olds during their second
and third trimesters of pregnancy.
812/26/2023

82. Pregnancy over age 35
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin




Preexisting conditions (cardiovascular disease, kidney
disorders, obesity, or diabetes) which increase risks
associated with pregnancy
Gestational diabetes, hypertensive
disorders of pregnancy, and other complications
Have low-birth-weight infants and chromosomal
abnormalities, especially Down syndrome
Have twins and triplets with increased nutrient
needs and preterm delivery
822/26/2023

83. Nutritional requirement during lactation
2/26/2023 Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 83

84. Introduction
84



Lactation is a period when a woman produces breast
milk
After birth, circulatory levels of estrogen and
progesterone are decreased while prolactin levels
remains elevated
Initiation of lactogenesis is hormone related however,
stimulation by infant suckling or other means must be
provided within the first few days for the continuation of
the process
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

85. Anatomy of the breast
85Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

86. The rooting reflex
86




An innate response
All newborn babies will turn their heads toward
anything that strokes their cheek or mouth and
open the mouth-rooting reflex
Required for successful suckling in order to
stimulate the nerve endings that lie beneath the
areola
Correct attachment or “latching-on” is
important
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

87. 87Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

88. Endocrine control of lactation
88



Lactation is under the control of a cascade of hormones
of hypothalamic and pituitary origin
The hypothalamus releases prolactin releasing hormone
(PRH), which stimulates secretion of prolactin
Prolactine is involved in milk secretion
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

89. Endocrine control of lactation
89








Secretion of oxytocin by the posterior pituitary is
stimulated by nerve impulses from the hypothalamus
Oxytocin helps ejection of milk in to ducts
The coordinated secretion of prolactin and oxytocin is
called the letdown reflex
Letdown reflex is triggered by suckling or sound of a baby
crying
The coupling of synthesis and release indicates that
lactation is demand-driven
Inhibited by anxiety, fatigue, embarrassment
However, breast feeding is a learned behavior
Some decide to stop or not start at all
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

90. •
•
Milk letdown is stimulated by
activation of mechanoreceptors in the
nipple
The hypothalamus coordinates the
response to stimulation, involving
oxytocin and prolactin, thereby
ensuring that milk synthesis and
release occur simultaneously
90
Fig: The neuroendocrine control of lactation
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

91. Synthesis of milk
10







Women will produce 750–800ml of milk per day at the
peak of lactation
Approximately 50% of the energy will be delivered as fat
and 40% as carbohydrate
True composition of milk varies
Maternal diet
Stages of lactation
Time of the day- more fats in the night
Within a course a feed (fore/hind milk)
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 912/26/2023

92. Composition of breast milk
92




Colostrums :
Colostrums is the earliest form of breast milk
It is yellowish and relatively viscous solution consisting of a
variety of dissolved or suspended substances such as
electrolytes and immune factors
Is lower in fat than protein as compared to BM after one
month
Over the first two week – gradually gets converted to mature
BM
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

93. Composition of milk at different
stages
93Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

94. Components of
BM
94
Function
s
Whey


Caesein
s
Energy source ( -lacatoalbumin
predominant protein
Energy source ( low content relative to
cow’s milk) ; carrier of Ca, Fe,Zn Cu
and Phosphate

Development of tissue
Protective against bacterial and virus
infections
Promotes formation of healthy
bacterial
colonization in infant’s lower GI
Iron binding protein that reduces the
availability of iron to bacteria in the GIT

Destroys bacteria
Kills bacteria by destroying the cell wall
PUFA ( DHA, EPA, AA)
Immunoglobulins (IgA ,IgM, IgE, EgD)
Bifidus Factors
Lactoferin

Lactoperoxidas
e Lysozyme
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

95. Macrophages
95
Destroy bacteria by phagocytosis,
synthesizes lactoferin and lyzozyme


Decreases Vitamin B
12
availability
for growth of bacteriaVitamin B
12
binding protein
Interferon Interferes with viral replication
in host cells
Lymphocytes


Antistaphylococcus
factor
Synthesizes IgA


Inhibits the growth of
staphylococcal
bacteria
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

96. Maternal nutrition during lactation

•
•
•
•
•
Lactation places high demands on maternal stores of
energy, protein and other nutrients.
These stores need to be established, conserved and
replenished.

Virtually all mothers, unless extremely malnourished,
can produce adequate amounts of breastmilk.

The energy, protein and other nutrients in breastmilk
come from a mother’s diet or her own body stores.

Women who do not get enough energy and nutrients
in their diets risk maternal depletion.


Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 962/26/2023

97. Maternal nutrition during lactation…
•
•
•
•
Maternal deficiencies of some micronutrients can affect the
quality of breastmilk.

These deficiencies can be avoided if the mother improves her
diet before, during and between cycles of pregnancy and
lactation, or takes supplements.

Women who breastfeed requires approximately 500kcal/day
additional(2 extra meal) beyond what is recommended for non-
pregnant women.

The estimate is derived from the mean volume of breast milk
produced per day (mean 780 mL, range 450-1200 mL) and the
energy content of milk (67 kcal/100 mL).

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 972/26/2023

98. Maternal nutrition during lactation…
•
•
•
•
During pregnancy, most women store an extra 2 to 5 kg
(19,000 to 48,000 kcal) in tissue, mainly as fat, in physiologic
preparation for lactation.
If women do not consume the extra calories, then body
stores are used to maintain lactation.

It is not unusual for lactating women to lose 0.5-1.0
kg/month after the first postpartum month.
However, weight loss during lactation does not usually
impact the quantity or quality of breast milk unless maternal
deficiencies in desired micronutrient have been manifested
during lactation.

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 982/26/2023

99. Maternal nutrition during lactation…
•
•
•
To meet intake of adequate nutrient requirements, a diversified
diet that includes fruit, vegetables and animal products
throughout the life cycle help ensure that women enter
pregnancy and lactation without deficiencies and obtain
adequate nutrients during periods of heightened demand.
Some nutrient requirements, particularly iron, folic acid and
vitamin A, are more difficult to achieve than others through food
sources.
For this reason, supplements with these nutrients are
recommended in addition to improved diets.

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 992/26/2023

100. Maternal nutrition during lactation…
•
•
•
•
There are even less evidence-based recommendations for
nutrient intake during breastfeeding compared to pregnancy.
Lactation is considered successful when the breast-fed
infant is gaining an appropriate amount of weight.

The recommended daily allowance for protein during
lactation is an additional 25 g/day.
Requirements of many micronutrients increase compared to
pregnancy, with the exception of vitamins D and K, calcium,
fluoride, magnesium and phosphorus.


Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1002/26/2023

101. Maternal nutrition during lactation…
•
•
Both fat-soluble (vitamins A, D, K) and water-soluble vitamins
(vitamins C, B1, B6, B12, and folate) are secreted into breast milk
and their levels are reduced in breast milk when there is a
maternal vitamin deficiency.

Fortunately, these vitamin deficiencies in breast milk respond to
maternal supplementation but can also be achieved without
dietary supplements given a balanced diet and the right food
choices.



Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1012/26/2023

102. Special Considerations during lactation
Multiple Gestations:

•
•
•
Multiple Gestations; the production of milk is primarily
determined by infant demand rather than the maternal
capacity to lactate.

As such, for women attempting to breastfeed twins and
triplets, the supply will meet the demand.
Continuation of micronutrient supplementations given
during antenatal period is appropriate for women who are
breastfeeding twins.

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1022/26/2023

103. Special Considerations…
•
•
•
Periodic avoidance of animal source foods: women may
have a habit of avoiding foods from animal origin
periodically or permanently for various reasons (religious,
intolerance with milk intake, etc.).

Supplementing vitamins B12 (2.6 μg/d), vitamin D are
recommended for women who do not drink milk or other
food fortified with vitamin D.
Another recommendation is to consume iron, zinc, calcium
(1200-1500 mg/day) because of the possible decreased
intake and absorption from a plant-based diet.

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1032/26/2023

104. Special Considerations…
•




Obesity: Several studies have demonstrated that women
with obesity have decreased rates of initiating
breastfeeding and breastfeed for shorter durations
compared to normal weight women.
Biological (i.e. delayed lactation)
Psychological (i.e., embarrassment related to body
size and difficulty in breastfeeding discreetly)
Mechanical (i.e., larger breasts and nipples that
create difficulties with latching) and
Medical (i.e., cesarean deliveries, diabetes and
thyroid dysfunction) factors have been theorized to
explain these findings, but the exact etiology is likely a
combination of factors.

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1042/26/2023

105. Special Considerations…
•
•
•
Other conditions: There are emerging conditions like
bariatric surgery and gastric banding for body weight
monitoring that affect nutrient absorption in the gastro-
intestinal tract.

The infant’s provider also should be aware of the mother’s
history of bariatric surgery as well as any of her specific
dietary restrictions or identified nutrient deficiencies.

For women who have a gastric banding procedure, one
recommendation is to keep the band deflated until the
successful establishment of breastfeeding.

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1052/26/2023

106. Special Considerations……
•
•

Alcohol: can impair milk ejection and infants seem to respond
to alcohol-induced flavor changes by consuming less milk.
Though occasional use of small amounts of alcohol in a
lactating women is unlikely to pose significant risk, therefore,
avoid high-dose or chronic alcohol consumption in lactating
women.



Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1062/26/2023

107. Nutrition during childhood period
2/26/2023 Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 107

108. Nutrition
during
infancy
108Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

109. Infancy
109




Is a period from birth to the completion of
first year
Characterized by the most rapid growth in
human life
Length is doubled and weight is tripled
Head circumference is also increased by
about 30%
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

110. Nutrition During infancy and childhood
•
•
•
•
Energy needs remain high through the early formative years.
While most adults require 25–30 calories/kg/day
Infant up to 4 months requires more than 100 kilocalories per
kg (430 calories/day).
Infants of four to six months require roughly 82 kilocalories
per kg (490 calories/day).
Children of one to three years require approximately 83
kilocalories per kg (990 calories/day).
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
110
2/26/2023

111. Nutrition During…..
•
•
Energy requirements decline thereafter and are based on weight,
height, and physical activity.
Increased requirements of energy, protein, essential fatty acids,
calcium and phosphorus.
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
111
2/26/2023

112. Essential Nutrition
Actions:

An action oriented approach to
nutrition
proven actions to prevent
malnutrition

Dr. Haji
Aman(
1122/26/2023

113. 

III. What actions to take/to Integrate?

7 action areas
6 contact points

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 113
Essential Nutrition Actions
2/26/2023

114. Federal MOH based on the ENA approach:
proven actions to prevent malnutrition
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 114
Control of
Anemia
Optimal
Breastfeeding
Control of
Vitamin A deficiency
Control of Iodine
Deficiency Disorders
Women’s Nutrition
Complementary
Feeding to BF
Feeding
of the sick child
2/26/2023

115. Recommendations
•
•
•
•
•
•
•
Essential Nutrition actions during the first 24 months
Optimal Breast feeding
Optimal Complementary feeding

Essential Nutrition actions 2-9 years
Diversified diet (Animal source food is essential)
Iron, vitamin A, iodine
Increase energy

Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
115
2/26/2023

116. 1. Promotion of Optimal Breastfeeding
Dr. Haji Aman( PhD, Asst. Professor in Human
Nutrition
116
Exclusive
Breastfeeding
for the first 6
months of life
National Strategy for IYCF, Fed MOH, April 2004
2/26/2023

117. 1. Promotion of Optimal Breastfeeding
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
117
Exclusive
Breastfeeding
for the first 6
months of life
National Strategy for IYCF, Fed MOH, April 2004
Estimated decrease of
child mortality: 4%
2/26/2023

118. 1. Promotion of Optimal Breastfeeding
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
118





Early Initiation of BF within 1 hour of birth
Exclusive BF until 6 months
BF day & night at least 10 times
Correct positioning & attachment
Empty one breast & switch to the other

Key Messages
National Strategy for IYCF, Fed MOH, April 2004
2/26/2023

119. Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
119
2/26/2023

120. Correct positioning
•
•
•
•
1. Body are in straight line (neck not twisted);
2. Baby is held close to the mother’s body,
3. Baby is held facing the breast; and
4. Baby’s whole body is supported.
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
120
2/26/2023

121. Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
121
2/26/2023

122. Correct attachments
•
•
•
•
1. more areola is seen above the baby's mouth than below;
2. Baby’s mouth opened fully
3. Baby’s lower lip opens outwardly
4. Baby’s chin touches her breast
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
122
2/26/2023

123.
Expressing milk is useful to:

•




Leave breast milk for a baby when a mother goes out
or goes to work.
Feed a low-birth-weight baby who cannot breastfeed.
Feed a sick baby, who cannot suckle enough.
Help with breast health conditions, e.g. engorgement
(This helps particularly to those mothers who
discontinue to breastfeed because of work.)

Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
123
2/26/2023

124. Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
124
2/26/2023

125. 3. Breast-feeding a sick child:

•
•
•
Key Messages for sick child feeding
During illness breastfeed more frequently

After illness continue to breastfeed more frequently for two weeks

If infant is too sick to suckle, then express breast milk and give
with a cup

Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
125
2/26/2023

126. 2. Complementary Feeding to BF
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
126
at
6 months
of age
National Strategy for IYCF, Fed MOH, April 2004
2/26/2023

127. 2. Complementary Feeding to BF
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
127
at
6 months
of age
National Strategy for IYCF, Fed MOH, April 2004
Estimated decrease of
child mortality: 8%
2/26/2023

128. 2. Complementary Feeding to BF
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
128






Continue BF until 24 months & more
Increase the number of feedings with age
Increase density & quantity with age
Diversify diet using variety of foods
Responsive feeding
Food hygiene
Key Messages
National Strategy for IYCF, Fed MOH, April 2004
2/26/2023

129. Use FADUA for CF …
•
•
•
•
•
•
•

Give solid/ semi solid complementary food at 6 months
The CF should fulfill “FADUA” criteria

F= frequency
A= amount
D= Density
U= utilization (hygiene)and utensils
A= Active feeding
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
129
2/26/2023

130. Frequency = increase frequency of
feeding with age of the child…
Age
(mont
hs)
Meal frequency
per day for
breast fed baby
Meal frequency
per day for non-
breastfed baby
 
6-9
2-3 times
+
1-2 snacks
4-5 times
+
1-2 snacks


10-23
3-4 times
+
1-2 snacks

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1302/26/2023

131. Amount: Mother increases the amount
of food the baby eats as the baby grows older.
Age
(month
s)
Amount of K
calorie for the
breast fed baby
Amount of K calorie
for the non-breast
fed baby
6-8
200 Kcal 600Kcal
9-11
300Kcal 700Kcal
12-23
550Kcal 900Kcal
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1312/26/2023

132. Density: Increases food thickness (density) and variety
as the child gets older, adapting to the child's nutritional
requirements and physical abilities

•
•
•
•
•
At 6 months mother or caregiver gives infant pureed,
mashed, and semi-solid foods.

Mother breastfeeds until child is at least 2 years old
(continue breastfeeding).

Add protein-rich foods (animal/plant): power flour, beans,
soya, chick peas, groundnuts, eggs, liver, meat, chicken,
milk.
Diversify the child’s food
Fermentation, germination
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
132
2/26/2023

133. Utilization: Mother or caregiver practices
good hygiene and safe food preparation.
•
•
•
•
Feeds liquids from a small cup or bowl.

Avoid bottle feeding as they are difficult to keep clean, and contaminated
bottles can cause diarrhea.

Before feeding child, mother or caregiver washes her/his hands and child’s
hands with soap and water and uses clean utensils and bowls or dishes to
avoid introducing dirt and germs that might cause diarrhea and other
infections.

Mother/caregiver can use her fingers (after washing) to feed child. Mother
or caregiver serves food immediately after preparation.
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
133
2/26/2023

134. Active feeding: Mother or caregiver interacts with
child during feeding (responsive feeding)
•
•
•
•
•
•
Mother or caregiver :
The child should have his/her own plate.
Feeds infant directly and helps older child eat.
Experiments with food combinations, tastes, textures, and ways to
encourage child who refuses many foods.
Minimizes distractions during meals if child loses interest easily.
Remembers that feeding times are periods of learning and love,
talking to child during feeding with eye-to-eye contact.
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
134
2/26/2023

135. Enrichment of CF with nutrients
Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1352/26/2023

136. 3. Feeding of the sick child
•



Key Messages
Increase breastfeeding & complementary feeding during &
after illness
(IMCI- Integrated Management of Childhood Illness)

For infants 6 months & older, feed 1 extra meal each day for
two weeks following the illness

Appropriate Therapeutic Feeding

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1362/26/2023

137. 4. Women’s Nutrition
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
137

-
-
-




During pregnancy & lactation
Iron/Folic Acid Supplementation
Treatment & prevention of malaria
Increase food intake
one extra meal each day during pregnancy
two extra meals each day during lactation
Deworming during pregnancy
Vitamin A Capsule within 45 days of delivery
Key Messages
National Strategy for MN, Fed MOH, April 2004
2/26/2023

138. 4. Women’s Nutrition
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
138

-
-
-




During pregnancy & lactation
Iron/Folic Acid Supplementation
Treatment & prevention of malaria
Increase food intake
one extra meal each day during pregnancy
two extra meals each day during lactation
Deworming during pregnancy
Vitamin A Capsule within 45 days of delivery
Key Messages
National Strategy for MN, Fed MOH, April 2004
Estimated decrease of
child mortality: 1%
2/26/2023

139. 5. Control of Vitamin A Deficiency
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
139





Breastfeeding: source of Vitamin A
Vitamin A rich foods
Maternal supplementation
Child supplementation
Food fortification
Key Messages
National Strategy for MN, Fed MOH, April 2004
2/26/2023

140. 5. Control of Vitamin A Deficiency
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
140





Breastfeeding: source of Vitamin A
Vitamin A rich foods
Maternal supplementation
Child supplementation
Food fortification
Key Messages
National Strategy for MN, Fed MOH, April 2004
Estimated decrease of
child mortality: 10%
2/26/2023

141. 6. Control of Anemia
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
141





Supplementation for women &
children (IMNCI)

Deworming for pregnant women &
children (twice/year)
Malaria control
Iron-rich foods
Fortification
Key Messages
National Strategy for MN, Fed MOH, April 2004
2/26/2023

142. 6. Control of Anemia
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
142





Supplementation for women &
children (IMCI)

Deworming for pregnant women &
children (twice/year)
Malaria control
Iron-rich foods
Fortification
Key Messages
National Strategy for MN, Fed MOH, April 2004
Estimated decrease of
child mortality: 0.4%
2/26/2023

143. 7. Control of Iodine Deficiency Disorders
Dr.
Haji
Ama
n(
PhD,
Asst.
Prof
esso
rin
143


Access & consumption
by all families
of iodized salt
Key Messages
National Strategy for MN, Fed MOH, April 2004
2/26/2023

144.

6 contact areas
1.
2.
3.
4.
5.
6.

Pregnancy
Delivery
Post natal & Family planning
Immunization
Well child & Growth monitoring/promotion
Sick child clinic

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1442/26/2023

145. DELIVERY: safe delivery, BF,
Vitamin A, iron/folic acid, diet, FP,
STI prevention
PREGNANCY : TT, antenatal
visits, BF, iron/folic acid, de-
worming, anti-malarial, diet, risk
signs, FP, STI prevention, safe
delivery, iodized salt
POSTNATAL AND FAMILY
PLANNING: diet, BF,
iron/folic acid, diet, FP, STI
prevention, child’s
vaccination
WELL CHILD AND GMP: monitor
growth, assess & counsel on
infant feeding, iodized salt, check
& complete vaccination
SICK CHILD: monitor growth,
assess & treat per IMCI, counsel on
infant feeding, BF, assess & treat
for anemia, check & complete
vitamin A /immunization/ de-
worming
IMMUNIZATION:
vaccinations, vitamin A, BF,
de-worming, assess & treat
infant’s anemia, FP, & STI
referral
Critical contacts for infant feeding,
& women’s nutrition: life cycle
Dr. Haji
Aman(
1452/26/2023

146. 1. Health facility level:1. Health facility level: integrate ENA actions into
existing health contacts at all health services;
2. Community-level:2. Community-level: work with community-based
organizations & networks from all sectors; &
3. Behavior change:3. Behavior change: reinforce ENA actions
through behavior change communication at all levels,
including inter-personal communication, mass media
& community mobilization.
When should we integrate?
Dr. Haji
Aman(
1462/26/2023

147. Child Survival
EPI+
Community IMCI
Health facilities IMCI
Reproductive Health
Women’s Nutrition
Lactation Amenorrhea Method
Infectious
Diseases
Control of Malaria
Mosquito net & Treatment
Tuberculosis
HIV/AIDS (PMTCT)

National
Immunization
Days
Polio
Measles
ENAENA
Essential Nutrition Actions expands
nutrition coverage within the health sector…
D
r
147
2/26/2023

148. SchoolsSchools
Adolescent nutrition
De-worming
Iron supplementation
School lunch
AgricultureAgriculture
Food diversification
Food security
Women’s farmers clubs
SanitationSanitation
Clean water & sanitation
Public health education
Prevention of diarrhea,
malaria, ARI
EmergencyEmergency
Food Supplementation
CTC
TFC
EOS
ENAENA
Essential Nutrition Actions expands
nutrition coverage outside the health sector…
D
r
148
Community Nutrition
Com Workers: HEP,DA,etc
Positive deviance
Community GM/P
2/26/2023

149.







149Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition2/26/2023

150. •


Nutrition during childhood
Haji Aman( PhD fellow in Human Nutrition 150

151. Child Growth
•
•
•
“The child is the father of the man” [William Wordsworth
(1770–1850)]
“The child is the mother of the woman”

Highest rate of growth attained during first two years,
especially, the first year of life

Growth is a very good indicator of child well being

Growth failure in early childhood (stunting) may be
irreversible to a large extent


Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1512/26/2023

152. Food preferences and behaviors
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




Child preferences are limited
May exclude nutritious foods
Child preference can be affected by parental knowledge,
limited food availability, and adaptation to newly
introduced food
Milk is the main source of nutrients for 1-4yrs old children
in most setting
Milk delivers much of the energy, protein and MN needs
of these children

153. Food behaviors







Eating habits form early in life
Children will adapt to foods offered to them
A variety of food should be offered to young children
A child may need to be exposed to a new food at least
10 times before accepting it
Division of responsibility
Parents = What, when, and where food is offered
Child = Whether or not to eat, and how much
Haji Aman( PhD fellow in Human Nutrition 153

154. Food preferences



Parents have strong influence over children’s food
preferences
Children model after adult behaviors, both healthy and
unhealthy
Including young children in food shopping, menu
planning, and meal preparation can encourage variety in
their food consumption
Haji Aman( PhD fellow in Human Nutrition 154

155. Food preferences









Picky eating and food jags are common
in young children
Picky eating – not wanting to try new food
Food jags – tendency to eat only a small
selection of food
Very common and normal, but also temporary
Can be identified through a food diary
Long-term jags increase risk of nutrient
deficiency
Solutions include:
Offering a variety of food items within the
preferred food type
Gradually weaning the child from the food item
Haji Aman( PhD fellow in Human Nutrition 155

156. Eating patterns and nutrient needs







Young children need to eat frequent, small
meals and nutrient-dense foods
Energy needs:1,000–1,600 kcal per day
The formula for Estimated Energy Requirements (EER)
for children ages 13–36 months is (89 × weight of child
[kg] – 100) + 20 (kcal for energy deposition).
Appropriate portion sizes:
Child-sized plates and cups
One rule of thumb for serving size is 1 tablespoon
of food per year of age
Start from small portion size and only provide if
children ask for more
Haji Aman( PhD fellow in Human Nutrition 156

157. Nutrient needs






Carbohydrate
At least half of grain intake should be from whole
grains
Protein
RDA (toddlers) = 1.1 grams per kg of body weight
Fat
Ages 2–3 years old = 30–35% of kilocalories from
fat
Haji Aman( PhD fellow in Human Nutrition 157

158. Nutrient needs: calcium and iron








Calcium
Necessary for healthy bone development
Ages 1–3 years need 500 milligrams per day
200 ml of milk provides 300 milligrams
Iron
Necessary during periods of rapid growth
Good sources of iron for children include lean meats, beans, and
iron-fortified cereals
Cow’s milk is a poor source of iron
Haji Aman( PhD fellow in Human Nutrition 158

159. Nutrition
during
adolescence
1Haji Aman( PhD fellow in Human Nutrition

160. Introduction
Haji
Ama
n(
PhD
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

WHO defines adolescence as age group
from 10-19 years while the American
Academy of Pediatrics defines it as 13
-18 years
Adolescence is the transitional stage that
lies between childhood and adulthood

161. Introduction
Haji
Ama
n(
PhD
fello
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


The period is characterized by rapid, physical, emotional,
social, sexual, psychological, development and maturation
Nutritional status is influenced by physical, psychological
and sociocultural aspects of adolescence
Adolescents mature earlier in developing countries and take
on adult roles in contrary to their Western counterparts

162. Adolescent growth
5




Second highest rate of growth attained, second to the first
year of life
More than 20% of total growth in stature and up to 50% of
adult bone mass are achieved
Nutrient requirements are significantly increased above
those in the childhood years
Among girls, the "growth spurt" or peak growth velocity
occurs normally about 12-18 months before menarche at
some time between 10 to 17 years
Haji Aman( PhD fellow in Human Nutrition

163. Adolescent growth
Haji
Ama
n(
PhD
fello
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6


Timing of the growth spurt is earlier in girls than in boys,
occurring at around the time the breasts begin to grow
(thelarche; one of the earliest indicators of female
puberty)
In boys sexual maturation has generally advanced to a
relatively late stage before the onset of the growth spurt

164. Adolescent growth
7




Growth in stature continues for up to 7 years after
menarche in girls
Maximal adult height in women may be attained
as early as 16 years or as late as 23 years
The development of the birth canal is not fully completed
until about 2-3 years after growth on height has ceased;
whereas peak bone mass is not achieved until the age of 25
years
The adult height finally attained may still differ as
a result of pre-existing childhood stuntingHaji Aman( PhD fellow in Human Nutrition

165. Adolescent growth
Haji
Ama
n(
PhD
fello
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


In both sexes, weight gain is proportionally greater than
height gain (e.g., girls gain 20% of adult height and 50% of
adult weight during the growth spurt), leading to an
increased body mass index
Boys tend to grow taller than girls because they enter
puberty at a later stage.
Similarly, girls who are “late developers” and enter puberty
at an older age will generally attain a greater than average
height due to their extended premenarche growth phase.

166. Adolescent growth



The growth spurt impacts upon all parts of the body, but the
timing of regional growth is uneven
Growth is sexually dimorphic, in terms of the timing and final
achieved heights and the distribution of increasing mass.
The growth period depends on the onset of sexual maturity (it
ceases earlier for males than females)
Haji
Ama
n(
PhD
fello
w in
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9

167. Average ages of pubertal, cognitive,
and psychosocial maturation.
Haji
Ama
n(
PhD
fello
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Hum
18

168. Normal psychosocial development
Haji
Ama
n(
PhD
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





The need to fit in can affect nutritional
intake
Who they eat with
Where they eat
Peer influences may be greater than family
May improve dietary intake
May lead to poor dietary intake

169. Critical actions- adolescents
•
•
•
•
•
Improving dietary intake
Implication:
How much height will be gained- the elevated Growth
Hormone hastened growth only in pre- menarcheal
subjects

Growth & hastening of menarche- linear growth was less
attained after menarche

Simultaneous fat gain- might lead to obesity in those
stunted but not thin




Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1692/26/2023

170. Critical actions- adolescents
•
•
•
•
•
Other benefits of food supplementation apart from linear
growth:
Weight gain among thin adolescent girls
Improved micronutrient (particularly iron & folate)
status,
Improve their wellbeing in the present as well as their
nutrition status during any subsequent pregnancy

Thus promotion of a balanced diet during
adolescence need not wait for the results of a
longitudinal study

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1702/26/2023

171. Critical actions- adolescents
•
•
•
•
•
•
Delaying the first pregnancy:
Approaches might include:
Incentives to delay marriage until after 19 years of
age;
Incentives for girls to stay in school;
Research & policy development
Ensuring availability of contraceptives to adolescents,
& their use

Dr. Haji Aman( PhD, Asst. Professor in Human Nutrition 1712/26/2023

172. Nutritional needs in a time
of
change
Haji
Ama
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PhD
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



Health-enhancing eating behaviors
Healthful eating practices
Physical activity
Interest in a healthy lifestyle
172

173. Calcium requirements for
adolescents
Haji
Ama
n(
PhD
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


Adequate intake of calcium is critical to
ensure peak bone mass
Calcium absorption rate in females is
highest around menarche
Calcium absorption rate in males
highest
during early adolescence

174. Calcium requirements for
adolescents
Haji
Ama
n(
PhD
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


~4 times more calcium absorbed during
early adolescence compared to early
adulthood
Adolescences who do not include dairy
should consume calcium-fortified foods
Soft drink consumption displaces
nutrient- dense beverages such as milk &
fortified juices

175. Iron requirements for adolescents
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Ama
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





Increased iron needs related to:
Rapid rate of linear growth
Increase in blood volume
Menarche in females
In females, iron needs greatest after
menarche
In males, iron needs greatest during the
growth spurt

176. Eating disorders
Haji
Ama
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PhD
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

Conditions marked by extreme emotions,
attitudes, and behaviors related to food,
eating, and weight
May cause damage to health or threaten
life

177. Anorexia nervosa
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Ama
n(
PhD
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


An intense fear of gaining weight—see self
as fat
Develop unusual eating habits
Strenuous exercising

178. Anorexia nervosa
Haji
Ama
n(
PhD
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









Starvation diet takes a toll on the body
Lower heart rate
Breathing rate
Blood pressure
Body temp
Lead to heart problems, osteoporosis,
constipation
Stunted growth
Stop menstrual cycle
Kills approximately 5% of all who suffer from it
Death by heart attack, electrolyte imbalance, and
suicide

179. Binge eating disorder
Haji
Ama
n(
PhD
fello
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


Eat abnormally large amounts of food
in a short time
Approximately 3,000-5,000 in one sitting
Occurs when alone followed by
feelings of guilt, disgust and
depression

180. Binge eating disorder
Haji
Ama
n(
PhD
fello
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





Unbalanced diet and emotional distress
can
lead to:
Leads to excessive weight gain
High blood pressure
High cholesterol
Heart disease
Diabetes especially if predisposed
180

181. Bulimia nervosa
Haji
Ama
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








Binge eating is followed by purging to rid the
body of the food and calories and prevent weight
gain
2 or more times a week
Purging includes
Self-induced vomiting
Abuse of laxatives
Diet pills
Diuretics (water-removal pills)
Fasting
Excessive exercise

182. Bulimia nervosa
Haji
Ama
n(
PhD
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




Fear getting fat but usually stay 5-7kg within
healthy weight
Signs of bulimia
Missing food
Discovery of laxatives
Long periods in bathroom after meals

183. Bulimia nervosa
Haji
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PhD
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








Health problems
Vomit eats away
Constant sore throats
Electrolyte imbalance
Irregular heart beat and possible heart
failure
Physical signs include
Stained, decayed teeth
Scarred, blistered hands
Unusual swelling around jaws

184. Nutrition during
adult
years
184Haji Aman( PhD fellow in Human Nutrition

185. Introduction
Haji
Ama
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185




Adulthood is subdivided into the
following segments
Young adult years (19-30): this time adults
have generally stopped growing
Middle adult years (31-50): body
composition shifts, hormones shift, and
activity decreases
Old adult years (51-70): experience
consequences of earlier lifestyle choices

186. Middle adult years (ages 31 to 50)
Haji
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186



Hormonal changes in men and women
differ :
In men, testosterone levels begin to decline around ages
40 to 50, although sperm can fertilize eggs until much
later
In women, the reproductive cycle lasts approximately 40
years, with 13 menstrual cycles per year

187. Older adult years (ages 51 to 70)
Haji
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187




Muscle mass and strength decrease with age, but
exercise can offset this decline
Lack of exercise results in loss of muscle mass, which in
turn decreases overall lean muscle mass, increases body
fat, and decreases metabolic rates leading to weight gain
Decreased immune system
Major changes occur in the ability to taste and smell food

188. Physiological changes during adulthood
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188



Men and women continue to develop bone
density until roughly age 30
Muscular strength peaks around 25 to 30 years of age
The type and amount of physical activity has a significant
impact on body composition, including lean body mass
(musculature), fat accumulation and relocation, and bone
density

189. Body composition changes in adults
Haji
Ama
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

The years between ages 20 and 64 are typically associated
with a positive energy balance with an increase in weight
and adiposity and a decrease in muscle mass
This redistribution of body fat is associated with increased
risk for hypertension, insulin resistance, diabetes, stroke,
gallbladder disease, and coronary artery disease
189

190. Changing needs for nutrients
Haji
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190



There is no significant different in the nutrient
needs during adulthood
As there is no longer a demand associated with growth and
maturation, requirements for most nutrients is lower in
adulthood than was seen in adolescence
Protein and micronutrient requirements are unchanging
across the earlier adult years

191. Energy adjustments for weight change
Haji
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


A decrease in weight leads to decrease in
calorie requirement
Obese person requires more energy
The combination of less calorie intake and increased
physical activity lead to weight loss

192. MyPyramid
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192

193. Nutritional risk factors of
chronic
diseases
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







Cancer -Carcinogenic diet
Low fruit and vegetable intake
Low level of antioxidants (especially vitamins A, C)
Low intake of whole grains and fiber
High dietary fat intake
Nitrosamines, burnt and charred food
High intakes of pickled and fermented food
Alcohol consumption ???
High animal-, low plant-food intake
193

194. Obesity: Obesogenic diet
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





Caloric intake exceed needs
Unstructured eating
Frequent fast-food consumption
High fat intake
Sugar-sweetened beverage consumption
Energy-dense, low-nutrient food choices

195. Nutrition during
aging
and elderly
195Haji Aman( PhD fellow in Human Nutrition

196. Introduction
Haji
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196




The elderly population are generally considered to be those
individuals who are aged 65 and over.
Increasing population of elderly in the world
It is also the most neglected stage in the
life cycle
Most health problems in elderly are consequences of
earlier nutritional , health or dietary status

197. Theories of aging
Haji
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

Biological systems are so complex that no single theory
has been robust enough to explain the mechanisms of
aging.
Some factors:
Genetics – explains 1/3
Environment- Nutrition genomics
Body composition

198. Physiological changes with aging
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







Changes in body composition
Decline in immune system
Changes in gastrointestinal tract
Dental problems
Sensory losses
Eating alone
Changes in support system and/or
environment
Polypharmacy

199. Changes with aging
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


Around age 25–30 the average maximum attainable heart
rate declines by about one beat per minute, per year
Heart’s peak capacity to pump blood drifts
down by 5%–10% per decade
This diminished aerobic capacity can produce fatigue and
breathlessness with modest activity

200. Changes with aging
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



Starting in middle age blood vessels begin to
stiffen and blood pressure often creeps up.
Blood becomes more viscous and harder to pump through
the body, even though the number of oxygen-carrying red
blood cells declines
Nutrition recommendations:
Low sodium diet (1500-2000 mg/day) with potassium
rich foods (DASH), omega 3’s found in fish help thin
blood

201. Changes with aging
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

Blood sugar levels rise by about 6 points per decade,
making type 2 diabetes distressingly common in elderly.
Nutrition recommendations:
Avoid excess weight gain, encourage activity

202. Changes with aging





In men, testosterone declines by about 1% per year after
the age of 40 leading to a drop in muscle mass and bone
density.
In women bone loss mainly occurs after menopause
(estrogen loss)
Nutrition recommendations:
Calcium requirements increase (from 1000mg to 1200 mg after age 50 in
women, 1200 mg after age 70 in men)
Vitamin D requirements increase (from 15 ug/d to 20 ug/d after age 70)
Haji
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202

203. Changes with aging
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203






Slowing of the digestive tract, decreased digestive
secretions
Dietary changes, activity changes, and medications can
also play causal role
Nutrition recommendations:
Increased fiber needs, 21 g for women and 30 g for
men
Diet that includes nuts, fruits, veg, and whole grains
should provide fiber needs
Fluid, exercise can also help constipation

204. Changes with aging
204







The senses of taste and smell
Inadequate diet
Zinc deficiency
Loss of taste buds
Dental health
Lack of dental hygiene and dental care
Gum disease cause tooth decay
Haji Aman( PhD fellow in Human Nutrition

205. Changes with aging
205










Liver, gall bladder and pancreas
Decreased efficiency of liver function
Decreased functioning of gall bladder
Renal function
Reduced glomerular filtration and tubular
reabsorption
Affect the excretion of waste and reabsorption
Immune function
Efficiency of immune system declines
Adequate protein and zinc is helpful
Over nutrition is also harmful to the immune system
Haji Aman( PhD fellow in Human Nutrition

206. Changes with aging
206








Hearing and vision
Decline with age
Affects to access food
Affects food preparation
Intake of “nutritious” foods
Lung function
Lung efficiency declines with age
Aggravated in smokers and tobacco user
Haji Aman( PhD fellow in Human Nutrition

207. Changes with aging
207






Change in body composition
Muscle cells shrinks and lost
Water and lean body mass decline
Percentage of body mass increase
Collagen increases and it becomes more rigid
Exercise increases lean body mass and food
intake by increasing energy expenditure
Decreased bone mass especially for women
Haji Aman( PhD fellow in Human Nutrition

208. Common nutrition related disorders
Haji
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


Osteoporosis
Loss of bone density, resulting in fractures
More common in women than men
Diet and exercise can help treat
osteoporosis, but may not prevent it in older
adults

209. Common nutrition related disorders
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


Vision Problems
Cataracts—thickening of eye lens
Macular degeneration—deterioration of
the center of the retina, which is
responsible for straight-ahead vision
Antioxidants in foods may protect against
vision loss

210. Common nutrition related disorders
•

•


Arthritis
Osteoarthritis—cushioning cartilage in joint
breaks down
Rheumatoid arthritis—disease of the immune system with
painful inflammation of the joints
Overweight can affect arthritis
Haji
Ama
n(
PhD
fello
w in
Hum
210

211. Common nutrition related
disorders
Haji
Ama
n(
PhD
fello
w in
Hum
211


Alzheimer’s Disease
A healthy diet can help promote brain
health
Research on a connection between diet
and Alzheimer’s disease is ongoing

212. 18/04/2016 DPFH
50
Haji Aman( PhD fellow in Human Nutrition 212