Lifecycle Nutrition

Developmental NutritionFCSN 345Dr. Virginia BennettOffice 134 PEOffice hours: T & Th 1:00e-mail: bennettv@cwu.edu

Measures of a Successful Outcome of PregnancyHealthy BabyHealthy MotherBaby Survives the First Year of Life

Healthy BabyStill Birth Ratio or Fetal Death RatioEarly in Pregnancy: difficult to have reliable numbers of death rateWhy?Later in Pregnancy: numbers are more reliable after 20 wks gestationAbout 6.4 stillbirths per 1000 live births

Healthy Mother: Maternal MortalityStatic since 1982 at 7 to 8 mothers die per 100,000 births. About 1 death per day in the USBig racial difference:White 5.0Black 20.8Others 18.2 Why?

Maternal Mortality

Infant MortalityInfancy: First Year of Life28 days < 1 year - postneonatal2006: Infant Mortality Rate in US6.43 per 1000 live birthsRanked 42nd world-wide1950 29.2 but we were ranked 6th world-wideWhy?

terminologyInfant: first year of lifeNeonatal: under 28 days of lifeEarly Neonatal: under 7 days of lifePost neonatal: 28 days 11 monthsFetal mortality: fetal deaths over 20 weeks gestationLate Fetal mortality: deaths over 28 weeks gestation

Cause of Infant ProblemsNeonatal Problems: first 28 days after birthWhat might be the reasons for problems here?4.7 in 2002Post neonatal Problems: 28 days to one yearWhat might be the reasons for problems here?2.3 in 2002

In USMost infant deaths happen in neonatal periodPerinatal mortality: adds fetal deaths plus early neonatal deaths

Better Infant Mortality RatesJapan: 3.24Singapore: 2.29Sweden: 2.76Hong Kong 2.95Cuba 6.22CIA - The World Factbook -- Rank Order - Infant mortality rate

Risk of Infant Mortality: FactorsIf infant mortality rate was similar to Singapores we would save over 18,900 infant deaths per yearLow Birth Weight largest single factorless than 5.5 pounds (2500 grams)LBW risk factors:K maternal pre-pregnancy ht & wt and pregnancy weight gainagesocioeconomicpovertynumber of pregnanciesrace

Classification of Low Birth WeightPremature< 37 weeksIntrauterine Growth Retardation or Small for Gestational Age37 weekswasted - thin, wt, normal lengthstunted - wt lgth head circum

Infant Mortality Rates by Maternal Race

Sheet:

White

Black

Native Amer

Asian or Pacific Islander

All Races

Mechanism for growth retardation

How to improve Infant Mortality Rate?HousingSanitationDietHealth care

Nutrition Influences on Fetal GrowthDeficiency in CaloriesToo few Calories to allow adequate reproduction of cells and decreased developmentDeficiency of NutrientsToo little of some specific nutriente.g.: folic acidspina bifida

Spina Bifida: A Neural Tube Defect

Winick: Growth Happens in Two WaysIncreased number of cellsIncreased size of cellsCritical times of increased number of cells1. Increased numberhyperplasia2. Number and size + hypertrophy3. SizeHypertrophy

Critical PeriodsIf an embryo or fetus doesnt receive the nutrition necessary to help with development, the fetus will sufferFertilization of the ovum(zygote) happensimplantation of the ovum in the uterine wall happens in the first two weeksCritical period: cigarette smoke, malnutrition can keep development from occurring

Types of Fetal Growth FailureIntrinsic: some internal factorchromosome abnormalitiesdrug affecting cellsExtrinsic: some external factorpoor intake of nutrientspoor blood supply

Is the fetus a perfect parasite?What does this mean?Fetus takes what it needs regardless of mothers intakeProbably isnt true.It takes what it needs until it disrupts mothers ability to surviveFrom a species survival standpoint: mother needs to survive

Events of PregnancyTimeEvent0-2 weeksegg fertilized and implanted3-8 weeksEmbryo: at end of 8 weeks is 1 inch and has central nervous system, GI tract, limb, buds, etc.8-40 weeksFetal period: growth and development

Role of the PlacentaNutrient and waste product exchangeHormone productionEstrogen: helps develop the infrastructure of pregnancyProgesterone:Relaxes smooth muscleRelaxes the uterusRelaxes the digestive system: slower movement

Placenta RolesTransport Mechanisms:Passive Diffusion: Oxygen-Carbon dioxideFatty acids-SteroidsNucleosides-ElectrolytesFat-soluble vitamins

Role of the Placenta

Placenta is Selectively PermeableNot all molecules can cross the placentaVitamin D canParathyroid Hormone (PTH) cantAllows for bone remodeling

Placental TransportFacilitated Diffusion:Most monosaccharidesActive Transport:Amino acids--some cations (Ca, Iron)Iodine--PhosphateWater-soluble vitamins (at high concentrations Vitamin C can pass via diffusion)Solvent Drag: electrolytes

Pregnancy

Nutrient Needs to Support PregnancyEnergy:No increase in Cal for first trimesterWhy?: 1. Very small embryo; 2. Increased absorption of most nutrients and Cal due to decreased motility of GI tract due to hormones of pregnancy300 Cal increase during 2nd and 3rd trimester

Nutrient Needs During PregnancyProtein:Determine pre-pregnancy needs based on RDA: 0.8 grams protein/kg. This is generally around 45 to 50 grams Protein per day.Add 15 grams to this for pregnancyGenerally around 60 to 65 grams/day is sufficient

Methyl-H4 FolateH4 FolateMoleculeMethylated MoleculeMethionine HomocysteineMethylene-H4 FolateserineglycinePurine precursorpurineSAM SAHB12

Nutrients of Special InterestFolate: related to neural tube defects and spina bifidaReduced absorption during pregnancy because of interaction with estrogenProduces folate deficient womenInterferes with proper formation of spinal column: affects 400,000 births per yearFolate supplements during pregnancy required

Nutrients of Special InterestIron: Blood volume increases by 50% during pregnancyBody conserves Iron during pregnancyNo menstruation3 time increase in absorptionBut still doesnt keep up with production of red blood cellsHemoglobin concentration falls: normal above 13 g/dl. In pregnancy may fall below 12 g/dlRDA up from 15 to 30 mg/day

Special Supplemental Food Program for Women, Infants, and ChildrenTo battle against problems during pregnancy and infancy, WIC was developed to provide supplemental food to low socioeconomic and at risk women and infants.Nutrition education also providedRecent study: for each $1 spent, $4 save down the road; Avg costs: Normal Birth Weight= $1,700; Premie or low birth weight = $77,000

Information on WIChttp://www.fns.usda.gov/wic/In 2005 we had about 8 million receiving WIC assistance in the US; This cost about $1.4 BillionIn 2005 we had about 160,000 receiving WIC assistance in Washington; This cost about $28 Million dollars

Body Mass IndexKg/ meters 2

175#/2.2 #/kg = 79.5 kg72 X .0254 meters/inch = 1.83 meters1.83 meters 2 = 3.35

79.5 / 3.35 = 23.7

Weight Gain During PregnancyBased on Pre-pregnancy BMIUnderweight (BMI

Wt Gain for multifetal pregnanciesTwins: 35-45 lbs. Underwt at the upper end of range; overwt at the lower end4-6 lb first trimester; 1.5 lb/wk after450 Cal per day above prepregnancy amountTriplets: 50 lbs with 1.5 lb/wk throughout pregnancyCal intake should reflect enough intake to meet wt gain goals

Average weight of multifetal pregnanciesSingletons: 7.7 lbs(3440 grams)Mean gestational age: 39-40 wks6% lbwTwins: 5.4 lbs(2400 grams)37 weeks; 54 % lbwTriplets: 4.0 lbs(1800 grams)33-34 wks; 90% lbw

Rate of Weight GainFirst Trimester: 2 to 4 poundsSecond and Third Trimester: 1 pound per week3 pounds + (26 weeks x 1 # per week) = 29#

Components of Weight GainInfant7.5 #amniotic fluid2 #Placenta1.5 #mothers stores7 #Blood4 #Fluid4 #uterus2 #Breasts2 # TOTAL 30 #

Fetal Alcohol SyndromePhysical and Mental Abnormalities attributed to alcohol consumption during pregnancylow nasal bridgesmall head short nose circumferenceshort eyelid openingdelayed thin upper lip developmentunderdeveloped filtrum

Source of FAS Informationhttp://www.nofas.org/http://capwiz.com/nofas/issues/alert/?alertid=6804721&type=COAdvocacy Extra credit assignment: write a letter to your members of congress

FAS ScreeningIn 1996, FAS Facial Photographic Screening/Diagnostic software (Astley & Clarren, 1996; 2001; Astley et al., 2001; Astley & Kinzel, 2002). The software is used to measure the magnitude of expression of the three facial features of FAS (small eyes, a smooth philtrum and a thin upper lip).

FAS ScreeningFAS is characterized by growth deficiency, a unique cluster of facial features, cognitive/behavioral problems and prenatal alcohol exposure. The facial appearance is the only feature that is unique to FAS, thus it serves as an ideal feature to use for screening. The screening tool performed with 99.9% accuracy.

Alcohol Effects on PregnancyAbout 1/5 of women continue to during pregnancyThe first few weeks are critical; many women dont know they are pregnantBirth defects have occurred in women who consume as little as two drinks per dayNo alcohol is the best if planning pregnancyFetal Alcohol Effects: internal damage

Other Dietary Concerns during PregnancyCaffeine:Animal models: massive doses are teratogenicSmaller doses not as definitivemixed results in epidemiological studiesgenerally if caffeine is consumed, it should be moderately

Sugar SubstitutesSaccharin: A carcinogen? Limit during pregnancyDoses relationship: high intake = greater riskAspartame (Nutrasweet): PKU mothers should avoidIf not PKU, moderate intake probably ok but need to increase Cal (2nd and 3rd trimesters) and Calcium

Maternal Problems of PregnancyGestational Diabetes: Glucose IntoleranceHormones of pregnancy make mothers body resistant to insulin;Human Placental Lactogen (HPL); Human Growth Hormone(HGH)Often shows up at 25 weeks of pregnancyNeeds to be treated to control growth of the fetusMacrosomia: large baby and delivery complications

Gestational Diabetes DxGlucose Tolerance Test (GTT):After Fasting:Glucose Load given orallyBaseline Blood Glucose (BG)BGs every hour for three hourstwo abnormally high values indicate Db Dx

Normal BG valuesFasting105 mg/dl1 hr1902 hr1653 hr145

Normal and Abnormal Glucose Curves

Sheet:

fasting

1 hours

2 hours

3 hours

normal

Db

Db

Treatment of Gestational DbDiet alone Calculate CHO needed: Generally 50 % of CalCould be less if poor controlDistribute them throughout the dayDevelop and Meal Plan for MotherInvolves Food RecordsWeight ChecksKetone TestingBlood Glucose Testing

Gestational Db TreatmentDiet and InsulinSome individuals are never able to control BG by diet alone and require insulin injectionsSame concerns as diet aloneWith emphasis on hypoglycemia

Gestational Diabetes ResourcesAmerican Diabetes Associationhttp://www.diabetes.org/gestational-diabetes.jsp

Other Problems of PregnancyEdema: most women suffer from water retention: due to large blood volume and decreased protein concentration in bloodPregnancy Induced Hypertension (PIH)massive edema, high blood pressure, protein in urineIf untreated can result in fetal and maternal injury or death

PIH: formerly called ToxemiaElevated BPProteinuriaMassive edemaOften called preeclampsiaEclampsia: a result of severe preeclampsia: convulsions and coma Can result in the death of the mother and fetus

Treatment of PIH: Diet??Nutritionally: offset protein loss with additional protein in dietSome research shows calcium supplementation may help prevent; mixedMagnesium supplementation may helpSodium restriction DOES NOT HELP treat or prevent

Treatment of PIH: Diet??Antioxidants: Vit C, E, caroteneHypertension often requires blood pressure lowering medicationDepending on severity, may require bedrest

Pica and CravingsPica: Eating Non-foodsgeophagia: eating dirtIron deficiency?: problem if it causes a blockageamylophagia: eating clothing starchCravings:eg: dill pickles and ice creamreason? Overcome a deficiency?No harm, no need for concern: If harmful, intervention is needed

Nutritional Guidance During PregnancyPositive approach to nutrition and pregnancyStress positive outcomes Vs fear of negative outcomeStress the importance of good nutritionadequate protein of good qualityenough total Cal, esp CHO, to spare protein balance of vitamins and minerals from fruits and vegies

Nutrition and PregnancyAge and Parity of MotherPreconception NutritionMetabolic Interaction of Pregnancy: synergismIndividual needs and adaptations

Nutrition AssessmentClinical ObservationsBody MeasuresLab TestsDiet History

Lab Tests Can Indicate ProblemsAnemia of PregnancyIron Deficiency: Most Commonalso called microcytic, hypochromic, with reticulocytes( immature RBCs)treated with supplements of Iron (30 mg/day)Other Anemias:Folic Acid deficiencyalso called megaloblastic anemia; disrupts hemoglobin synthesisB12 Deficiency: Called pernicious; also big cells

Blood measures: AnemiaHematocrit: Packed RBC VolumeNormal non-pregnancy: 35 %During pregnancy 29-31%HemoglobinNormal non-pregnancy: 13-14 g/100mlPregnancy: 10-11 g/100ml

Images of Anemiahttp://health.allrefer.com/health/iron-deficiency-anemia-reticulocytes.html

Folic Acid AnemiaRDA up from 180 micrograms to 400 micrograms / dayEstrogen Folic Acid Interactions1. Disrupts absorptiondisrupts an enzyme that helps with absorption(deconjugase)2. Increases clearance of folic acid from blood

B12 DeficiencyPernicious Anemiasimilar to megaloblastic but caused by deficiency of B12If untreated, may also be associated with neurological damage

http://health.allrefer.com/pictures-images/megaloblastic-anemia-view-of-red-blood-cells.html

Phenylketonuria and PregnancyPKU: genetic disease, passed autosomal recessive traitInability to metabolize extra Phe to Tyrosinemissing Phenylalanine hydroxylaseresults in high phenylketones in mother and fetal circulationcan cause mental retardation in fetus

Red Flags During AssessmentDisproportionate height to weight and weight gainAbuse or avoidance of foodsbizarre eating patternseconomic or psychological problems associated with foodunhealthful lifestyle with or without substance abuse

Lactation

3 Factors to Establish and Maintain BreastfeedingAnatomyInitiation of productionEjection of milk from alveoli

AnatomyFunctional BreastsLarge variation in structureBut almost all women who have given birth who want to breastfeed their babies can

Development of BreastsPuberty: increased estrogen associated with development of mammary glands and alveolar cells and ductsPregnancy: further proliferation of alveoliBirth: increase prolactin production and secretionFurther alveolar cell proliferation

Physiology of LactationFull Lactation may not be attained until 2nd or even 3rd week (in first pregnancy)Colostrum: first secretion: high in protein, low in sugar and fatFirst 2+ days and then transition to milkYellowhigh in immunoglobulins

Prolactin: Control of Milk ProductionComplex neuroendocrine processSensory nerves of breast stimulatednerve impulse travels to spinal cord and hypothalamusInduces pituitary gland to produce and secrete hormonesMajor one is PROLACTIN

Cycle of ProductionResting CellMilk synthesisMilk secretionResting Cell

Prolactin ControlFat Prolactin increases two enzymesInduces lipoprotein lipase production which removes Triglycerides from circulation and moves fatty acids and glycerol into alveolar cellsInduces a transferase enzyme that helps make triglycerides in the cell for milk production

Prolactin ControlProtein: casein and lactalbumin unique to milkProlactin increases production of these two proteins

Prolactin ControlCHO: lactoseGalactosyl transferase(inactive) | lactalbumin |Galactosyl transferase(GT)(active)

Glu + Gal-----------> Lactose GT

Maintenance of Milk ProductionSucking---hypothalamus--anterior pituitary---prolactin secretion---milk production and releaseIf no suckingNo milk productionDemand and Supplyless sucking, less production: more sucking, more production

Milk Letdown: moving the milk to nipple for baby accessControlled by oxytocinSucking----hypothalamus--posterior pituitary-----oxytocin releasemyoepithilial cell contraction in ductulesforces milk to nippleOther stimuli can induce this as wellcrying, embarrassment

Human Vs Cows milk(per Liter)Kcal: 668Pro(g):9%5.5%Fat(g):40%53.9%CHO(g)68%40.7%6783520.6%3850.4%4928.9%

Protein Content of MilkSpecies specific: The fastest newborn growth rate = the highest level of proteinCows grow real fast, therefore cows milk has relatively more protein than human milk.Why is more protein needed in cows milk?

Type of protein in milkHuman milk 40 % Casein, 60 % alpha lactalbuminCows milk 80 % Casein, 20 % alpha lactalbuminHuman milk low in PhenylalanineHuman milk high in cystine & taurineBabies cant synthesize these too well.

Taurine: a conditionally essential Amino Acid, not used in Protein SynthesisFound free or associated with small peptides:

Taurine FunctionTaurine function: Functions: Related to development in infantsAlso conjugation of bile acids; Taurine, called a bile salt, is lipophilic and hydrophilic; these are conjugated or connected to bile acids, the combination of which helps emulsify the fatty stuff of food and helps with digestion and absorption;

Taurine FunctionOther functions of taurine: detoxification, membrane stabilization, osmoregulation, and modulation of cellular calcium levels.

ColostrumHigh proteinlow sugar, fat and kcalImmunoglobulins IgA and IgGguard against intestinal tract infectionmay pass into circulation and guard against systemic infectionpassage of meconiumhelps establish bifidus flora in GI tract

Iron Supplementation and BFTwo Points of View:Yes: milk iron directly proportional to mothers intakeFetal Fe levels are generally low;Fe needed for growthNo: Fe saturates lactoferrin, the iron binding protein of milklactoferrin then unable to sequester Fe from pathogenic bacteria; leading to more infections

Vitamins: Cow Vs. HumanThe amount of vitamins in human milk varies more from individual to individual than does the average vitamin content of cows milk from the average vitamin content of human milk. Why?Diet, genetics, other factors

Vitamin K and InfantsInfants generally low Vitamin K statusIntestinal flora make Vitamin KNewborn gut is sterile, no bacteria to make Vitamin KBirth is traumaticVitamin K is important in blood clottingVitamin K injection at birth

Breastfeeding: Best Feeding MethodSole food for the first 4 to 6 monthsProvides benefits to baby and motherEconomicConvenienceNutritionImmune functionBondingMaternal weight loss

Anti-infective PropertiesBifidus factor: stimulates bifidobacteria, which fight against pathogenic bacteriaIgA, IgM, IgG: immunoglobulins that guard the gut against infective bacteriaLactoferrin: binds iron away from bacteriaMacrophages: phagocytosis of infective bacteriaB12 binding protein: removes B12 from bac.

When not to breastfeed?HIV infected motherAlthough WHO says go ahead in developing countriesThe risk of infection is less than the harm by not having good nutrition available during early monthsGalactosemia: one in 50,000 birthsInability to convert galactose to glucose and developmental problems result

Breastfeeding PromotionIncidence: how many select breastfeeding as a feeding choice: Breastfeeding at 1 weekDuration: how long does mother breastfeed? sole food for 5 to 6 months.By 2000, goals are 85% and 35%Peaked in 1984 at 61% and 24%dropping sinceWhy?

Breastfeeding Choice: FactorsEthnicity: Anglo 60.5%; Black 25%; Hispanic: 51%;Employment: Full 53 %; Part 62 %; None 53 %; Acculturation: Low 53 %; Middle 38 %; High 36 %;

Trisler, T. A., Bergman, E.A. JADA Suppl 93(9): A77.4 groups of breastfeeding promotionA: no peer present: Spanish taughtB: no peer present: English taughtC: peer present: Spanish taughtD. peer present: English taughtPresence of peer played no role in incidence of breastfeeding;Spanish taught increased rate of incidence

Behavioral Factors Involved in Breastfeeding DecisionSocial Support: availability of family membersSocial Influence; advertising, health professionalsAttitudes:attitudes toward formula and BFSelf-efficacy: confidence of the motherSummary: Must increase BF in minority populations

How to Influence Choice?J Nutr Ed: Teaching Intervention 1984: 16(1): 19-22.Three groups:A: Pregnant woman given referral card with telephone number with supportive messageB: Same with a manual in Spanish and EnglishC: Same with a bedside teaching session with BF consultant

JADA 1998;98:143-148.Counseling and Motivating videotapes increase duration of breast-feeding in African-American WIC participantsn=115 Af-Am women who initiated BFFour groups: A: no interventionB: video packageC: peer counselingD: bothMore breastfed in intervention groups

JADA 1998Group7-10 d8 wk16 wkControl53%23%*0%*video67%(n=33)75%(n=28)48%vi&peer80%70%40%*p

If Breastfeeding is not Chosen?Infant formula is next best choice:Most are cows milk derived and are produced to be close to human milk in compositionSome are soy basedOthers are specialized to meet certain needse.g.: PKU babies cant have very much phenylalanine in the diet: Lofenalac

Nutrition EducationInformative: Factual informationAttitudinal: motivates change in attitude about nutrition and nourishmentBehavioral: motivates change in behaviorTherapeutic: addresses a specific problem

When is Nut Ed needed?High Risk Groups: poverty, lack of education, very young(

Cost/Benefit of Nutrition Ed.WIC offers nutrition vouchers and nutrition education to high risk mothers.Data collected indicates that for each $1 spent, $4.21 is savedIndividuals who dont receive WIC are at greater risk for low birth weight babies, and other complications that lead to increased health care money spent.Nutrition Education Saves Money!

Costs of Low Birth BabyMedicaid pays an average of $77,000 for a low birth weight baby in additional hospital and health care expenses.A normal weight baby costs an average of $1700.Poor Fetal Nutrition is also linked to Chronic Disease

Lancet 348:1264-1268, 1996.N= 13,249 Death from heart disease and stroke tended to be higher in those men who were born with a low birth weight and remained small at 1 year of agePerhaps related to mothers ability to support pregnancy and trauma induced in the developing fetus.

Breastfeeding and FertilityBreastfeeding tends to suppress menstruation and ovulationAlmost all who formula feed initiate menstruation and ovulation soonerCan this be used as a contraceptive method?Probably not. Nutritional status also influences.

When to Add Solid Foods?4 to 6 months: when developmental landmarks are met; Continue breastfeeding or formulaIron fortified rice cerealAdd one food at a time: several daysSee if there is an allergic reactionThen add a new food

Problems of Infant FeedingFailure to Thrive:Baby doesnt grow as fast as peersCauses? Often inadequate nutritionMonitor weight gainCompare nutrient intake per body weightA baby needs more than an adult

Problems of Infant FeedingBaby Bottle Tooth Decay: Also called Nursing Bottle SyndromeExposure of teeth to the carbohydrates of formula

General Feeding Rules for Infants and ChildrenCaregiver is the gatekeeper: What is offered and whenInfant or child decides whether to eat what is offered and also how much

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