discipline specific core course nutrition for the …
TRANSCRIPT
Graduate Course
CONTENT
UNIT 1 : BASIC CONCEPTS OF MEAL PLANNING
Lesson 1 : Food Groups, Balanced Diet and Food Exchange List
Lesson 2 : Human Nutrition Requirements and Recommendations
Lesson 3 : Introduction to Meal Planning
Lesson 4 : Dietary Guidelines for Indians
UNIT 2 : NUTRITION DURING THE ADULT YEARS
Lesson 5 : Nutrition during Adulthood
Lesson 6 : Nutrition during Pregnancy
Lesson 7 : Nutrition during Lactation
Lesson 8 : Nutrition for Elderly
UNIT 3 : NUTRITION DURING CHILDHOOD AND ADOLESCENCE
Lesson 9 : Nutrition during Infancy
Lesson 10 : Nutrition for Pre-Schoolers
Lesson 11 : Nutrition for School aged children
Lesson 12 : Nutrition during Adolescence
Written by
Ms. Anjali
SCHOOL OF OPEN LEARNING
University of Delhi
5, Cavalry Lane, Delhi-110007
UNIT 1
BASIC CONCEPTS OF MEAL PLANNING
Lesson 1: Food Groups, Balanced Diet and Food Exchange List
Lesson 2: Human Nutrition Requirements and Recommendations
Lesson 3: Introduction to Meal Planning
Lesson 4: Dietary Guidelines for Indians
2
3
LESSON 1
FOOD GROUPS, BALANCED DIET AND FOOD EXCHANGE LIST
INTRODUCTION
Human life needs few things for survival, food being one of them as life cannot exist
without food. It is what matters to people most of the time more than anything else in this
world. The foods have direct impact on our capacity to enjoy life. The most obvious
positive effect of food is the pleasurable feeling one gets from eating a good-tasting meal.
Over centuries, food has acted as a vehicle for the expression of affection, and
companionship. It provides our bodies with nutrients to build new body cells and tissues;
to prevent and fight the infections. Apart from satisfying hunger, food performs many other
vital functions in the body.
OBJECTIVES
❖ To familiarise the concept of food groups.
❖ To understand the importance of a balanced diet in achieving good health.
❖ To introduce the concept of food exchange list.
FOOD GROUPS
Consumption of diet having all the nutrients in the appropriate quantity is essential. In order
to acquire the goodness of all the food groups in a diet, one must choose food items from
each food group depending upon the functions they perform like energy giving foods etc.
The ICMR has grouped the foodstuffs according to the similarity in the nutrients content
as it is not possible to consume all the food items in the diet at one time. Moreover, since
the food items varied in their nutrient quantity (more or less), the grouping of food was
required. Therefore, to overcome this problem, “Food Groups” have been made having
food items providing the similar nutrients.
Significance of food group system
The five food group system can be used for the following purposes:
• Planning normal or therapeutic diets to achieve nutritional adequacy.
• Assessing nutritional status – a brief diet history of an individual can disclose
inadequacies of food and nutrients from any of the five groups.
• Provides variety to the diet and makes it more appealing
Indian Council of Medical Research (ICMR) has classified the different food items into
five food groups, based on their nutritional content and for the ease of meal planning.
1. Cereals, grains and products
2. Pulses and legumes
3. Milk and meat products
4
4. Fruits and vegetables
5. Fats and sugars
1. Cereals, grains and products
The foodstuffs included in this group are rice, bajra, jowar, bread, maize, maida, etc. These
food items are rich in carbohydrates and energy. Being the cheapest sources of energy this
food group is an important part of the diet of all groups.
Along with energy and carbohydrates, this food group also have some amount of proteins.
As cereal is staple in Indian diets, plenty amount of proteins are derived from them.
However, it is important to know that cereals are poor in lysine and rich in methionine
while pulses are poor in methionine and rich in lysine. When cereals and pulses are mixed
in the same meal then the quality of protein improves. This process is called as mutual
supplementation.
The cereals are also abundant in B complex vitamins, provided one consumes whole grain
cereals. These B complex vitamins are absent in refined cereals such as maida etc. as the
outer layer of the cereal is removed in refined cereals. Whole-grain cereals are also rich in
minerals like iron, calcium etc. For e.g. bajra is rich in iron, ragi is rich in calcium. Cereals
lacks vitamin C, but its content can be enhanced by the processes of germination and
fermentation.
2. Pulses and legumes
This food group include various pulses and legumes, like green gram, black gram, beans,
etc. This food group provides good portion of protein in the vegetarian diet as pulses and
legumes are the rich source of proteins. The proteins provided by this food group is the
second class proteins. Second class proteins are the proteins which are derived from non-
animal related foods or plant sources, like vegetables and fruits.
Pulses and legumes ae generally consumed with cereals to ensure the quality of protein in
the diet as pulses and legumes lacks methionine which is abundant in the cereals. This
method of improving protein quality though pulse-cereal combination is called mutual
supplementation. Some of the examples of mutual supplementation found in Indian
kitchens are dal-roti, dal-chawal etc.
This food group also provides good amount of B group vitamins and minerals especially
thiamine. It does not contain Vitamin C, though, its content can be improved by the process
of germination and fermentation. Germination is also said to enhance the iron content of
the pulses.
Another good source of proteins ae nuts and oil seeds which is also a good source of energy
as it is rich in fats. Oilseeds like sesame seeds are also abundant in calcium.
3. Milk and meat products
This food group is further subdivided into two groups:
i. Milk and milk products.
ii. Eggs, fish, meat, poultry etc.
5
The food items in these food groups provide us with the first-class proteins. First-class
proteins are the proteins which are derived from animal sources and contain all the
Essential Amino Acids (EAA). Essential amino acids are the amino acids which cannot be
synthesized in the body on its own and thus one needs to take it in diet. There are nine
amino acids namely: Histidine, Methionine, Isoleucine, Leucine, Lysine, Phenylalanine,
Tryptophan, Threonine, and Valine.
i) Milk and its products - Milk and its products like curd, cheese are the rich source of
good quality proteins. It also provides us with calcium, phosphorous, vitamin A and
riboflavin. It is considered as an essential food for growing children, as it provides
them with first class protein and they are easily able to digest it.
ii) Eggs, meat, fish and chicken - These are excellent sources of first-class protein,
which can be totally utilized in our body. They also contain B-group vitamins in good
amounts. Among this, liver is a very good source of vitamin A and vitamin B12. Eggs
contain almost all the nutrients but are predominantly good source of protein, fats,
vitamin A, calcium and phosphorus.
4. Fruits and Vegetables
This food groups add taste, flavour, and varied colours to the diet. It can be sub-divided
into two groups. These food items in this food group provide vitamins and minerals which
gives protection from infections.
a. Vegetables
i. Green leafy vegetables
ii. Other vegetables
b. Fruits
Green leafy vegetables like mustard leaves (sarso), radish leaves, amaranth leaves (cholai),
fenugreek leaves (methi), and spinach (palak) etc. are included in this food group. These
leafy vegetables are a good source of vitamins and minerals like carotene (precursor of
vitamin A), folic acid and iron.
For e.g., 100 mg amaranth leaves contain 8553±1813 β- carotene.
The green leafy vegetables also provide a good amount of calcium, if consumed in the diet.
Other vegetables include orange and yellow coloured vegetables which provide us mainly
with carotenes and antioxidants. This group provides vitamins and minerals. Nutrients are
not destroyed as fruits are mostly consumed in the raw state. It also has lots of fibre content
which prevent constipation. Vitamin C is found in citrus fresh fruits.
Fruits also provide a good amount of vitamins and minerals along with dietary fibre to our
meals. The fibrous tissues, which are not digested, help to move the food through the
digestive tract and regulate the excretion of body wastes.
5. Fats and Sugars
Fats and oils like vegetable oils, vanaspati and ghee are dense sources of energy. One gram
of fat provides 9 Kcal. It is mostly used as the cooking medium and hence form a necessary
part of the diet of all section of the society. Fats also promote the absorption of the four fat-
6
soluble vitamins (A, D, E and K), impart a feeling of fullness and satisfaction and thus,
delay the onset of hunger. It helps to increase the palatability of our food. Fats are essential
for meeting some of the nutritional needs like essential fatty acids (linoleic n-6 and alpha-
linolenic n-3) and serve as rich sources of energy. Therefore, fats should be consumed, in
moderation. Dietary fats can be derived from plant and animal sources. Fats that are used
as such at the table or during cooking (vegetable oils, vanaspati, butter and ghee) are termed
as “visible” fats. Fats that are present as an integral components of various foods are
referred to as “invisible” fat.
Sugar, jaggery and honey supplies energy in the form of carbohydrates. Apart, from
providing carbohydrates, jaggery is also a good source of iron.
Types of Fat
All fats in foods provide mixtures of three types of fatty acids (Table 1.1), which are the
“building blocks” of fats. Fatty acids are the primary constituents of all dietary fats. Based
on their chemical nature, the fatty acids are broadly grouped as saturated (SFA),
monounsaturated (MUFA) and polyunsaturated (PUFA).
• Unsaturated fats
Unsaturated fats are the fats which are liquid at room temperature. They are considered
beneficial fats because they improve blood cholesterol levels, ease inflammation,
stabilize heart rhythms, and play a number of other beneficial roles. They are
predominantly found in foods from plants, such as vegetable oils, nuts, and seeds.
There are two types of “good” unsaturated fats:
a) Monounsaturated fats are found in high concentrations in:
o Olive, peanut, and canola oils
o Avocados
o Nuts such as almonds, hazelnuts, and pecans
o Seeds such as pumpkin and sesame seeds
b) Polyunsaturated fats are found in high concentrations in :
o Sunflower, corn, soybean, and flaxseed oils
o Walnuts
o Flax seeds
o Fish
The two essential fatty acids (EFA) are, linoleic (n-6) and alpha linolenic (n-3) acids
(important dietary polyunsaturated fatty acids). Linoleic (n-6) is metabolized at various
sites in the body to generate a group of biologically-active compounds, which perform
several important physiological functions. However, the body can’t make Omega-3 fatty
acids, so they must come from food. An excellent way to get omega-3 fatty acids is by
eating fish 2-3 times a week. Good plant sources of omega-3 fatty acids include flax seeds,
walnuts, and canola or soybean oil.
7
• Saturated Fats
All foods containing fat have a mix of specific types of fats. Even healthy foods like
chicken and nuts have small amounts of saturated fat, though much less than the amounts
found in beef, cheese, and ice cream. Saturated fat is mainly found in animal foods, but a
few plant foods are also high in saturated fats, such as coconut, coconut oil, palm oil, and
palm kernel oil.
Table 1.1: Major Types of Fatty Acids in Fats and Oils
Saturated Monounsaturated Polyunsaturated
Coconut
Palm kernel oil
Ghee/Butter
Vanaspati
Red palm oil
Palmolein
Groundnut
Rice bran
Sesame
Linoleic (n-6) a-Linolenic (n-3)
Low Red palm oil
Palmolein
Rapeseed,
Mustard, Soyabean
Moderate Groundnut
Rice bran
Sesame
High Safflower,
Sunflower,
Cottonseed,
Corn, Soyabean
(Source: ICMR, 2011)
• Trans Fats
Trans fatty acids, more commonly called trans fats, are made by heating vegetable oils in
the presence of hydrogen gas and a catalyst. This process is called hydrogenation.
Partially hydrogenated oil is not the only source of trans-fats in our diets. They are also
naturally found in beef fat and dairy fat in small amounts. They raise bad Low Density
Lipoprotein (LDL) and lower good High Density Lipoprotein (HDL), Create inflammation,
contribute to insulin resistance.
In view of the above, an ideal quality fat for good health is the one which maintains a
balance, so as to give a ratio of polyunsaturated/ saturated (PUFA/ SFA) of 0.8-1.0, and
linoleic/ a-linolenic (n-6/ n-3) of 5-10 in the total diet. For ensuring this appropriate balance
of fatty acids in cereal-based diets, it is necessary to increase the a-linolenic (n-3) acid
intake and reduce the quantity of linoleic (n-6) acid obtained from the cooking oil. Hence,
the choice of cooking oil should be as follows:
Use of more than one source of fat/oil has the added advantage of providing a variety of
minor components in the diet. An additional way of increasing alpha linolenic (n-3) acid
intake is to ensure regular consumption of oils and foods rich in alpha-linolenic (n-3) acid.
There are still number of food items that are still not covered in these food groups and are
used in our diets on regular basis like spices and condiments. The spices makes the food
palatable tasty, colourful and appealing do not contribute much to the nutritive value of the
diet.
The five food groups with their nutrients contribution is given in Table 1.2.
8
Table 1.2: Five Food Groups and their major nutrients.
Food Group Food items Main Nutrients
I. Cereal, grains and
products
Rice, Wheat, Ragi, Bajra,
Maize, Jowar, Barley, Rice
Flakes, Wheat Flour
Energy, Protein,
Invisible Fat,
Thiamine (Vitamin
B1), Riboflavin
(Vitamin B2), Folic
Acid (Vitamin B9),
Iron, Fibre.
II. Pulses and legumes
Bengal Gram, Red Gram,
Lentil, Black Gram Green
Gram, Rajma, Soybean, And
Beans.
Energy, Protein,
Invisible Fats,
Thiamine (Vitamin
B1), Riboflavin
(Vitamin B2), Folic
Acid (Vitamin B9),
Calcium, Iron, Fibre.
III. Milk and meat
products
Milk, Cheese Curd,
Chicken, Liver, Fish, Egg,
Meat
Protein, Fat,
Riboflavin (Vitamin
B2), Calcium.
IV. Fruits and vegetables
Fruits: Mango, Papaya,
Orange, Sweet, Guava, Lime,
Melon etc.
Vegetables: (Green Leafy):
Amaranth, Coriander,
Spinach, Mint, and Fenugreek
Leaves etc.
Other Vegetables:
Carrots, Ladyfinger, Beans,
Brinjal, Onions etc.
Vitamin A, Vitamin C,
Riboflavin (Vitamin
B2), Iron, Fibre.
Vitamin A, Riboflavin
(Vitamin B2), Folic
Acid (Vitamin B9),
Calcium, Dietary
Fibre, Iron.
Vitamin A, Folic Acid
(Vitamin B2),
Calcium, Dietary
Fibre.
V. Fats and Sugar
Fats: Butter, Ghee, Cooking
Oil etc.
Sugars: Honey, Sugar,
Jaggery
Energy, Fats, Essential
Fatty Acids (EFA)
Energy
(Source: ICMR, 2011)
9
VISUAL FOOD GUIDES
Food guides are primarily a guide to healthy eating. They are the pictorial representations
of food-based dietary guidelines (FBDG) that support national health programmes and
policies. These visual/graphic aids simplifies complex nutritional messaging for the public.
Some of the shapes that are used worldwide are Pyramid (India), Circle (US), Traffic light
(UK), Quarter rainbow (Canada) and Arrows (Italy) format etc.
Figure 1.1: Eatwell Guide- United Kingdom
The Eatwell Guide shows the different types of foods and drinks we should consume – and
in what proportions – to have a healthy, balanced diet. The Eatwell Guide shows the
proportions of the main food groups that form a healthy, balanced diet
(https://www.nhs.uk/live-well/eat-well/the-eatwell-guide/):
• Eat at least 5 portions of a variety of fruit and vegetables every day
• Base meals on potatoes, bread, rice, pasta or other starchy carbohydrates;
choosing wholegrain versions where possible
• Have some dairy or dairy alternatives (such as soya drinks); choosing lower fat
and lower sugar options
• Eat some beans, pulses, fish, eggs, meat and other proteins
• Choose unsaturated oils and spreads and eat in small amounts
• Drink 6-8 cups/glasses of fluid a day.
10
Figure 1.3: Food Guide Pagoda- China Figure 1.2: My Plate- United States
Figure 1.4: Food Guide- Australia
11
Indian Food Pyramid
The Food Pyramid has been adopted by many
countries and regions of the world to allow
populations to formulate a healthy diet plan for
themselves and their families. The dietary
guidelines were launched in 1998 which was
revised in 2011. India uses food pyramid (Figure
1.5) as a visual guide to represent the messages of
its dietary guidelines.
The pyramid is divided into four levels of foods
according to recommended consumption. There
is also a recommendation to do regular physical
activity and warnings against smoking and
drinking alcohol:
• At the base: Cereals and legumes/pulses
should be eaten in sufficient quantity,
• Second level: Vegetables and fruits should be eaten liberally,
• Third level: Animal source foods and oils are to be eaten moderately
• At the apex: Highly processed foods high in sugar and fat to be eaten sparingly.
BALANCED DIET
No food is complete in itself. In order to have all the nutrients in adequate proportion, we
must include different type of foods in our diet. A diet balanced for one may not be balanced
for the other person because nutritional requirements vary from person to person. For e.g.
an adult balanced diet cannot be given to a child as they both have different nutritional
requirements. The nutritional requirements are affected by different factors like age,
gender, climate, occupation, the composition of the body etc.
In order to provide the nutrients, good nutrition or adequate food consumption according
to the dietary needs of the human body is necessary. A well-balanced diet combined with
the regular physical activity is the foundation of good health. Poor nutrition can lead to
reduced immunity, increased susceptibility to disease, impaired physical and mental
development, and reduced productivity. Since a healthy diet consists of different kinds of
foods, therefore the food-based approach has been largely followed.
A healthy diet consumed throughout the life-course helps in preventing malnutrition in all
its forms as well as a wide range of non-communicable diseases (NCDs) and conditions.
But rapid urbanization/globalization increased consumption of processed foods and
changing lifestyles has led to a shift in dietary patterns. Eating a nutritious and balanced
diet is one of the best ways to protect and promote good health.
Figure 1.5: Indian food Pyramid
12
Food items from all the five food groups given by ICMR are included to make a diet
balanced to fulfil the nutritional needs of a person. A balanced diet is one which provides
all the nutrients in required amounts and proper proportions in a person’s diet without
increasing its calorie intake from the Recommended Dietary Allowance (RDA).
A balanced diet should also provide dietary fibre, antioxidants and phytochemicals which
bestow positive health benefits. Antioxidants such as vitamins C and E, protect the human
body from free radical damage and phytochemicals such as polyphenols, flavones, etc.,
prevent oxidative damage. Spices like turmeric, ginger, garlic, cumin and cloves are some
of the rich sources of antioxidants.
A balanced diet is the one which contains different types of food in adequate quantity
and right proportion so as to meet the nutritional requirements of our body. It can
easily be achieved through the combination of the five basic food groups. The amount of
food needed to meet the nutrient requirements vary with age, gender, physiological status
and physical activity. Around 50-60% of total calories should come from carbohydrates in
a balanced diet, preferably from complex carbohydrates, about 10-15% from proteins and
20-30% from both visible and invisible fat. Apart from providing adequate nutrients
for growth and maintenance, there is an extra provision for nutrients as a margin of
safety in the balanced diet. The margin of safety is used in stress conditions like during
fasting, fevers etc. where one is not able to consume the nutrients in the required amount.
Balanced Diet for Adults (man and woman) - Sedentary/Moderate/Heavy Activity is given
in Table 1.3.
Table 1.3: Balanced diet for adults-sedentary/ moderate/ heavy activity (No. of
portions) (ICMR, 2011)
FOOD GROUPS Type of work
g/
portion
Sedentary Moderate Heavy
Man Woman Man Woman Man Woma
n
Cereal, grains &
products 30 12.5 9 15 11 20 16
Pulses & legumes 30 2.5 2 3 2.5 4 3
Milk & milk products 100 ml 3 3 3 3 3 3
Roots & tuber 100 2 2 2 2 2 2
Green vegetables 100 1 1 1 1 1 1
Other vegetables 100 2 2 2 2 2 2
Fruits 100 1 1 1 1 1 1
Sugar 5 4 4 6 6 11 9
Fats 5 5 4 6 5 8 6
13
To calculate the day's requirement of above-mentioned food groups for an individual,
multiply grams per portion with no of portions.
An example of an adult woman day’s diet belonging to the middle-income group (MIG) is
given below.
Figure 1.6: Sample meal plan for an adult woman (sedentary) (ICMR, 2011)
FOOD EXCHANGE LIST
In food exchange system, foods are commonly grouped on the basis of similarities in their
nutrient composition. The exchange system makes diet planning more practical, flexible
and simple. It also helps in comparing energy and protein content with detailed calculations
using food composition tables. The exchange list of any food group includes specified
amount of various foods in that group with approximately equal carbohydrate, protein, fat,
vitamin and mineral content with exception of fruits and vegetables. Any food with in a
given list can be substituted for any other in the list and provide approximately the same
nutritive value. With the use of this exchange system, nutritionally balanced meals can be
easily planned by choosing adequate number of exchanges from each group. It is likely that
once the energy and protein requirement is met, other nutrient requirements are also likely
14
to meet except Vitamin A and C, which can only met by the judicious selection of fruits
and vegetables.
A comprehensive food exchange list developed by Department of Food and Nutrition, Lady
Irwin College, University of Delhi (Table 1.4) has seven main food groups which are Milk,
Meat and Pulse, Vegetables, Fruit, Cereal, Fat and Sugar. One exchange of each food group
represent commonly measured or purchased units of food or its multiple.
Table 1.4: Comprehensive Food Exchange List
S.No
.
Exchange Approx
amount
of raw
food (g)
Measure
of raw
food
Energy Protein
(g)
Carbohy
drates
(g)
Fat
(g) KJ KCal
1. i. Milk
ii. Skimmed milk
250
320
1 cup
1 ¼ cup
750
390
180
94
8
8
12
15
11
Neg
2. a. Meat, fish, poultry
i.Meat 1
ii.Meat 2
40
40
2 pieces
or 1 egg
2-3pieces
334
146
80
35
7
7
Neg
Neg
5
1
b. Pulses and legumes 30 3 tbsp 420 100* 7 17 Neg
3. a. Green leafy vegetables 100 1 cup 124 30* 3 2.5 Neg
b. Other vegetables 100-150 1 cup 124 30* 2 3.5 Neg
c. Roots and tubers 100 1 cup 210 50* 1.5 10 Neg
4. Fruit 80-100 1 portion 190 45* 1.0 10 Neg
5. Cereal/ Starch 20 5 tsp 215 75* 2 15 0.5
6. Fat
i. Oilseeds
8-12
1 tsp
190
45
2
Neg
5
Fats 5 1 tsp 190 45 Neg Neg 5
7. Sugar 6 1 tsp 84 20 Neg 5 Neg
The main features of each of the 7 food groups of the food exchange list are as follows:
1. Milk- exchange provides 8g protein which is further divided into milk and skimmed
milk. Cow’s whole milk forms the basis for one exchange which is equal to one cup of
milk.
2. Meat, Fish and Poultry exchange- these exchanges are characterised by high protein
content. One exchange of this food group provides 7g protein.
a. Based on fat content, the group is further subdivided into Meat 1 (5g fat) and Meat
2 (1g fat).
b. Pulses and legumes is also based on 7g protein and is usually equivalent of one
medium bowl of cooked pulse.
3. Vegetable exchange-is most variable in its nutritive contribution and hence is divided
into 3 sub categories:
a. Green Leafy Vegetables (GLVs) with 2.5g of carbohydrate are important as a
group for their iron, calcium and Vitamin A and C contribution.
b. Other vegetables group is formed on the basis of 3.5g carbohydrate and is
equal to approximately 100 to 150g of raw edible portion of vegetable.
15
c. Roots and tubers group has highest amount of carbohydrate among vegetables
and its exchange is based on 10g of carbohydrate.
4. Fruit exchange is equal to one medium fruit (80 to 100g) and provides 10g of
carbohydrate.
5. Cereal/starch is an exchange based on 15g carbohydrate and is about 20g in weight.
6. Fat exchange has also been divided into oils and fats and oil seeds. One exchange of
fat is based on 5g fat, which equals one teaspoon of oil.
7. Sugar exchange is based on 5g carbohydrate and is equal to one teaspoon of sugar.
Every food exchange also has a separate table of certain common foods from our earlier
food exchange lists or food labels as their values were not available in IFCT, 2017.
LET’S CHECK THE PROGRESS
1. Explain the following briefly:
• Indian Food Pyramid
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
• Food group
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
• Mutual supplementation
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
2. ‘A balanced diet for a person may not be balanced one for the other’. Justify.
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
3. What is a food exchange list? How is it useful?
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
16
SUMMARY
All the nutrients in the diet are provided by right amount and proportion of the all the food
groups. The quantity of the food group vary based on one’s gender, age, occupation and
the physiological condition. A balanced diet includes foods from all the food groups. It is
important that these foods should be in adequate quantities so that one’s daily nutrient
requirements can be met. ICMR has classified foods in 5 food groups- cereals, grains and
products, pulses and legumes, milk and meat products, fruits and vegetables and fats and
sugars. A food guide pyramid is a visual guide used by Indians to show the dietary
guidelines. With the use of this exchange system, nutritionally balanced meals can be easily
planned by choosing adequate number of exchanges from each group.
REFERENCES
➢ Chadha, R., & Mathur, P. (2015). Nutrition: A Lifecycle Approach. 1st Ed. Orient
BlackSwan.
➢ ICMR. Nutrient requirements and recommended dietary allowances for Indians. A
report of the expert group of Indian Council of Medical Research (ICMR), National
Institute of Nutrition, Hyderabad. 2010.
➢ Indian Council of Medical Research (ICMR). Dietary Guidelines for Indians-A
Manual. National Institute of Nutrition, Hyderabad, 2011.
➢ Institute of Medicine (IOM). Dietary References intake for energy, carbohydrate,
fibre, fat, fatty acids, cholesterol, protein and amino acids (macronutrients),
Washington, D.C.: National Academic Press, 2005.
➢ Seymour, D 1983, ‘The social functions of the meal’, International Journal of
Hospitality Management.
➢ Truman, E. (2018), "Exploring the visual appeal of food guide graphics: A
compositional analysis of dinner plate models", British Food Journal, Vol. 120 No.
8, pp. 1682-1695. https://doi.org/10.1108/BFJ-02-2018-0112 ➢ WHO. Energy and protein requirements: Report of a Joint FAO/WHO/UNU Expert
Consultation, WHO Technical Report Series 724, Geneva: World Health Organisation,
1985.
➢ http://www.fao.org/nutrition/education/food-dietary-
guidelines/regions/countries/India/en
https://sol.du.ac.in/solsite/Courses/UG/StudyMaterial/16/Part1/NHE/English/SM-
1.pdf
➢ https://ec.europa.eu/jrc/en/health-knowledge-gateway/promotion-
prevention/nutrition/food-based-dietary-guidelines
17
LESSON 2
HUMAN NUTRITION REQUIREMENTS AND RECOMMENDATIONS
INTRODUCTION
Today, nutritionists have an extensive understanding of the role of nutrients in health and
disease. People require different nutrients to maintain health and to reduce the risk of diet-
related diseases. The amount of each nutrient required in a body is called the nutritional
requirement. These are different for each nutrient and also vary between individuals and
life stages, e.g. women of childbearing age need more iron than men.
OBJECTIVES
❖ To familiarise the concept of nutrient requirements and recommendations.
❖ To understand the methods of estimating nutrient requirements.
❖ To introduce the Indian RDA and its uses.
IMPORTANCE OF KNOWING NUTRITIONAL REQUIREMENTS
Nutrient Requirement-The requirement for a particular nutrient is the minimum amount
that needs to be consumed to prevent symptoms of deficiency and to maintain satisfactory
level of the nutrient in the body.
We need to know nutritional requirements of an individual or group for two major
reasons:
i. Prescriptive reasons-To procure and secure food for national consumption so that
smooth running of nutritional supplementation programmes can be ensured.
ii. Diagnostic reasons-To identify whether a group or an individual is suffering from
malnutrition or to evaluate nutritional intervention programmes. To determine
whether the food available in the stock is adequate to feed the household or nation
for a certain duration of time.
Why do nutritional requirements differ?
Each nutrient play a set of functions in the body because of which it varies in quantities
needed in the body. For example, protein is needed in gram (g) quantities. Vitamin C is
needed in milligram (mg) quantities (1/1000 gram) and vitamin B12 is needed in microgram
(µg) quantities (1/1000000 gram). Individual requirements for each nutrient are related to
a person’s age, gender, level of physical activity and state of health. It also depends on the
absorption efficiency of some nutrients. E.g. vitamin B12 absorption.
To calculate Nutrient Requirements and Dietary Allowances for various groups, there are
some general rules that are followed. The nutrient requirements of an individual depends
upon the age, physiological and metabolic status and body weight of the individual and the
dietary allowances for a group or a population take into consideration variation among
individual within the group, effect of cooking, quality of the diet and processing and bio-
availability of its nutrient.
18
Reference Nutrient Intake (RNI)- It refers to the amount of a nutrient that is enough to
ensure that the needs of almost all apparently healthy individuals in an age and specific
population group (97.5%) are being met. It is set at EAR plus 2 standard deviations (SD).
The indicator of nutritional adequacy upon which the EARs and AIs are based is identified for
each nutrient and it may differ through life phases. Dietary Reference Intakes (DRIs) report
to the intake levels beyond which there is a potential for increased risk and adverse effects may
occur. It is defined as the lowest continuing intake level of a nutrient that, for a specific indicator
of adequacy, will maintain a defined level of nutrition in an individual (IOM, 1997). The
normal distribution of individual nutrient requirements forms the basis for computing RDA.
Figure 2.1: The Normal Curve
Normal distribution, also known as the Gaussian distribution. Normal distributions have
the following features:
• symmetric bell shape
• mean and median are equal; both located at the centre of the distribution
• ≈68% of the data falls within ±1 standard deviation of the mean
• ≈95% of the data falls within ±2 standard deviations of the mean
• ≈99.7% of the data falls within ±3 standard deviations of the mean
COMPONENTS OF DRI
Dietary Reference Intakes (DRIs) are novel concept to the field of nutrition which is meant
to replace the former Recommended Dietary Allowances (RDAs) in the United States and
Recommended Nutrient Intakes (RNIs) in Canada. It comprises of five nutrient-based
reference values. The DRIs differ from the former RDAs and RNIs in the following ways:
• Where specific data on safety and efficacy exist, reduction in the risk of chronic
degenerative disease rather than just the absence of signs of deficiency is included
in the formulation of the recommendation;
19
• Where data are adequate, upper levels of intake are established to prevent risk of
adverse effects; and
• Components of food that may not fit the traditional concept of an essential nutrient
but are of possible benefit to health will be reviewed and if sufficient data exist,
reference intakes will be established.
Where adequate information is available, each nutrient will have a set of DRIs. A nutrient
will have either an Estimated Average Requirement (EAR) and RDA, or an Adequate
Intake (AI). When an EAR for the nutrient cannot be determined and therefore, neither can
the RDA, then an AI is provided for the nutrient. In addition, most nutrients will have a
Tolerable Upper Intake Level (UL). Like the former RDAs and RNIs, each type of DRI
refers to the average daily nutrient intake of apparently healthy individuals over time,
although the amount may vary substantially from day to day without ill effect in most cases.
The reference values, which are used for assessing and planning diets for healthy people,
include five basic elements (Byrd-Bredbenner et al. 2013). Establishment of these
reference values requires that a criterion be carefully chosen for each nutrient and that the
population for whom these values apply be carefully defined.
• Estimated Average Requirement (EAR)
Estimated Average Requirement is the
average daily nutrient intake level
estimated to meet the requirement of half
(50%) of the “healthy” individuals in a
particular life stage and gender group.
The EAR's usefulness as a predictor of an
individual's requirement depends on the
appropriateness of the choice of the
nutritional status indicator or criterion
and the type and amount of data available.
The general method used to set the EAR is the
same for all nutrients.
• Recommended Dietary Allowance (RDA)
It is the average daily dietary nutrient
intake level sufficient to meet the nutrient
requirement of nearly all (97 to 98
percent) healthy individuals in a
particular life stage and gender group.
The RDA is intended to be used as a goal
for daily intake by individuals as this
value estimates an intake level that has a
% o
f in
div
idu
als
Nutrient Intake
% o
f in
div
idu
als
Nutrient Intake
20
high probability of meeting the requirement of a randomly chosen individual (about
97.5 percent). However the RDA is not an appropriate value to use to assess the
adequacy of intakes since it is a level above the requirement of most individuals in a
given population. RDA value of a nutrient is valid only when all other dietary nutrient
intakes are satisfactory.
RDA = EAR + 2SD (EAR)
RDA = 1.2 EAR
The RDA is derived from
• The individual variability, and
• The nutrient bio-availability from the habitual diet.
Individual variability- RDA takes into account the variability that exists in the requirement
of a given nutrient between individuals in a given population group. The distribution of
nutrient requirement in a population group is considered normal and the RDA corresponds
to a requirement, which covers most of the individuals (97.5%) in a given population. This
corresponds to Mean +2 SD. This is termed as a safe level of intake of a nutrient, that is,
the chances of individuals having requirements above the RDA is only 2.5%. This principle
is used in case of all nutrients except energy, since in the case of energy, intakes either the
excess or below the actual requirement of energy are not safe. In case of other nutrients the
RDA is 25% (+ 2SD) higher than the mean requirement, 12.5% being considered as the
extent of individual variability in the requirements of all those nutrients.
Bio-availability- Bio-availability of a given nutrient from a diet, that is, the release of the
nutrient from the food, its absorption in the intestine and bio-response have to be taken into
account. It is the level of the nutrient that should be present in the diet to meet the
requirement. This bio-availability factor is quite important in case of calcium and protein
and trace elements like iron and zinc. In case of iron, the amount to be present in the diet
Figure 2.2: RDA for energy and protein (Source: WHO 1985)
21
is 20-30 times higher than the actual iron
requirement to account for the low bio-availability
of iron from a given diet, particularly a cereal-
based diet.
• Adequate Intake (AI)- It is a recommended
average daily intake level based on observed or
experimentally determined approximations or
estimates of nutrient intake by a group (or groups)
of apparently healthy people, that are assumed to be adequate used when an RDA
cannot be determined. In the Indian context, this is referred to as acceptable Intake.
• Tolerable Upper Intake Level (UL)- It is the
highest average daily nutrient intake level that
is likely to pose no risk of adverse health
effects for almost all individuals in the
general population. As intake increases above
the UL, the potential risk of adverse effects
increases.
• Estimated Energy Requirements (EER)- According to Institute of Medicine (IOM),
EER is the average dietary energy intake that is predicted to maintain energy balance
in healthy, normal weight individuals of a defined age, gender, weight, height, and level
of physical activity consistent with good health. In children and pregnant and lactating
women, the EER includes the needs associated with growth or secretion of milk at rates
consistent with good health.
Lower Reference Nutrient Intake (LRNI)- The amount of a nutrient that is enough for
only the small number of people who have low requirements (2.5%). The majority need
more.
Safe intake- This is used where there is insufficient evidence to set an EAR, RNI or LRNI.
The safe intake is the amount judged to be a level or range of intake at which there is no
risk of deficiency and is below the level where there is a risk of undesirable effects. There
is no evidence that intakes above this level have any benefits - and in some instances they
could have toxic effects.
Adults need nutrients for maintenance of constant body weight and for ensuring proper
body function. Infants and young children grow rapidly and require nutrients not only for
maintenance but also for growth. They require relatively more nutrients (2-3 times) per kg
body weight than adults. In physiological conditions like pregnancy and lactation, adult
woman needs additional nutrients to meet the demand for foetal growth and maternal tissue
Nutrient Intake
% o
f in
div
idu
als
%
of
ind
ivid
uals
Nutrient Intake
22
expansion in pregnancy and milk secretion during lactation. These extra intakes of nutrients
are essential for normal growth of infants in utero and during early post-natal life.
ESTIMATING THE NUTRIENT REQUIREMENTS
A number of approaches have been used in arriving at the nutrients requirement of an
individuals and RDA for a population. The general principles are:
1) Dietary intake- In arriving at the energy requirement of children this approach is
used. Energy intakes of normally growing healthy children are utilized for this
purpose.
2) Growth-The requirement of any particular nutrient or breast milk intake for
satisfactory growth has been utilised for defining requirements in an early infancy.
3) Nutrient Balance-The minimum intake of a nutrient for equilibrium (intake =
output) in adults and nutrient retention consistent with satisfactory growth in infants
and children, have been used widely in arriving at the protein requirements.
4) Obligatory loss of nutrients-The minimal loss of any nutrient or its metabolic
product (viz. nitrogenous end products of proteins) through normal routes of
elimination viz. urine, faeces and sweat is determined on a diet devoid of, or very
low in the nutrient. This approach has been widely used in assessing the protein
requirement. Other losses of nitrogen through sweat, hair etc., are not considered in
this method.
5) Factorial approach-In this approach, the nutrients required for different functions,
are assessed separately and added up to arrive at the total daily requirement. This
has been the basis of computing the energy requirement. (viz., sleep + rest +
occupational activity+ non-occupational activity). This approach was being used
earlier for assessing the protein requirements also.
6) Nutrient turnover-Results from studies of turnover of nutrients in healthy persons,
using isotopically labelled nutrients are employed in arriving at the requirement of
certain nutrients. Requirements of vitamin A, vitamin C, iron and vitamin B12 have
been determined employing this approach. Earlier, radioactive isotopes were used
and currently stable isotopes, which are safer, are being increasingly used to
determine the turnover of nutrients in the body. Stable isotopes are particularly
useful, as they are safer, in determining the turnover of nutrients in infants, children,
in women particularly during pregnancy and lactation where use of radioisotopes
are contraindicated. Stable isotope labelled nutrients are however expensive and
difficult to obtain.
7) Depletion and repletion studies-This approach is used in arriving at the human
requirement of water-soluble vitamins. The level of the vitamin or its coenzyme in
serum or cells (erythrocytes, leucocytes) is used as the biochemical marker of the
vitamin status. Human requirements of ascorbic acid (vitamin C), thiamine (vitamin
23
B1) riboflavin (vitamin B2), and pyridoxine (vitamin B6) have been determined
employing this approach. Healthy volunteers are first fed a diet with very low levels
of the vitamin till the biochemical parameter of the vitamin (or its coenzyme)
reaches a low level. Response to feeding graded doses of the vitamin with the diet
is then determined. The level at which the response increases rapidly corresponds
to the level of the requirement of the vitamin.
8) Carcass analysis-Autopsy data has been used to get an idea of the nutrients retained
by the body. It is not a routine method but is used more in animal experiments. The
carcass or the dead body of the animal can be analysed for its nitrogen content or
trace mineral content (e.g. level of calcium, copper, zinc etc)
ENERGY
Energy needs are determined by energy expenditure. Therefore, in principle, as was
recognized in the report of the 1971 FAO Committee, estimates of requirements should be
based on measurements of energy expenditure. The components of energy expenditure
includes Basal Metabolic Rate (BMR), Specific Dynamic Action (SDA) and physical
activity. Total Energy Expenditure (TEE) can be calculated by the heart rate monitoring
method, doubly labelled water technique, energy balance method and factorial method.
• Heart rate monitoring method-This is an effective and cheap method of
estimating energy expenditure. In this method energy needs are estimated using
constant monitoring of heart rate. This method predicts whole body oxygen
consumption from measurements of the heart rate (HR).
• Energy balance method-For this method, energy expenditure and energy intake
have to be assessed. The energy value of food can be determined with the help of
bomb calorimeter. However, it is important that energy balance is maintained over
a long period by people with healthy body weight.
• Doubly labelled water technique-This technique is based on the fact that
hydrogen atoms of body water leave the body via the usual routes of water loss- in
urine, sweat, saliva and as evaporated water while the oxygen atoms of body water
leave the body by these same routes but also as carbon dioxide gas. Some of the
water in the body is labelled with two isotopes- 2H (deuterium) and 18O, which are
readily detectable. This is the best available method of assessing energy
expenditure. However it is expensive and requires technical skill in measurement.
• Factorial method-This method involves calculation of the energy needs of each of
the three components of energy expenditure. BMR is estimated using calorimetry
or using standard equations, 10% of energy intake is added for SDA and then the
cost of each physical activity is added.
24
PROTEIN
• Factorial approach- In this approach the requirements for different functions are
assessed separately and added up to arrive at the total daily requirements of protein.
• Balance studies-The minimum intake of protein for a state of equilibrium
(intake=output) in adults and nitrogen retention, consistent with satisfactory growth
in children have been widely used for arriving at the protein requirements.
VITAMIN AND MINERALS
• Balance studies-These are used for stable nutrients like calcium, iron and other
minerals where the intake and output routes are known and can be measured. If
intake=output then the person is in the state of equilibrium with respect to that
nutrient. If intake is greater than the output the individual is in positive balance, e.g.
a growing child is usually in a state of positive calcium balance, if intake is less
than output the individual is in negative balance, e.g. an elderly person or a bed
ridden person is usually in a negative calcium balance.
• Diet surveys- These are generally not used independently but in combination with
other methods like balance studies, etc. the intake levels of different nutrients of a
normal healthy population and/or a population group suffering from specific
nutrient deficiencies, can provide us with valuable information about intake levels
consistent with good health.
• Biochemical evaluation- Levels of nutrients and their metabolites in body fluids
like blood, urine and even faeces and levels in tissues like the liver, provide us with
vital information about the nutritional status of the individual. Sometimes the levels
or activity of enzymes which require specific vitamins or minerals for their
functioning are measured. Load tests with water soluble vitamins are conducted to
estimate nutrient status. Mega dose of the vitamin is given to the individual and
percent return of the test dose in urine is estimated between 4 to 24 hours. This
gives an indication about the level of tissue saturation. If the body tissues are
saturated with the vitamin, the % return (excretion) is high. If the tissues had very
low levels of vitamin then the % return is less. This method is employed for vitamin
C.
• Isotope tracers-In this approach labelled nutrients are injected or fed to the
individual and the turnover of nutrients is studied. Stable isotopes of vitamins like
A, C, B12 and iron have been used to estimate the requirements of these nutrients.
• Clinical evaluation- The deficiency of minerals and vitamins can cause specific
clinical signs and symptoms. The prevalence of these can be correlated with dietary
intake and with biochemical levels. For e.g. at what level of vitamin A intake does
an individual develop night blindness. Tests of mental and work performance or
functional tests also help in estimating vitamin and minerals requirements. For e.g.
25
ability to see in dim light (dark adaptation time) is studied with the help of
photometers in the assessment of vitamin A requirements.
• Growth- The requirement of any particular nutrient for satisfactory growth has
been used for defining needs during periods of rapid growth like infancy. The intake
of nutrient via breast milk has been linked to growth performance for nutrients like
energy. Zinc is the mineral which has been linked to growth performance.
• Depletion and repletion studies- This method has been used to estimate the
requirement of water soluble vitamins. The vitamin or its coenzyme levels in tissues
(e.g. WBCs, RBCs) or serum are used as a biochemical marker of its status.
Requirements of Vitamin B1, B2, B3, B6 and C have been established using this
approach. The subjects are fed a diet very low in the nutrient under the study till
biochemical parameters reach a low level. The response to feeding graded doses of
nutrient is then determined. The level at which the response increases rapidly is an
indication of requirement.
• Population studies- This is an epidemiological approach in which rates of
mortality (death), morbidity (illness), and prevalence rates of nutrient deficiency
diseases (like iron deficiency anaemia) are estimated by surveys.
LET’S CHECK THE PROGRESS
1. Define DRIs. Explain the elements of DRIs.
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
2. Discuss the various uses of RDA.
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
3. Explain how the following approaches are used to calculate nutrient requirements:
• Balance studies
--------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------
26
• Nutrient turnover
--------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------
• Depletion-repletion studies
--------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------
SUMMARY
In this lesson, we studied that human nutritional requirements are quantitative estimates of
the amount of nutrients that will meet the needs of 97 to 98% of individuals in a particular
life stage and gender group with zero risk of deficiency or excess. The median concept
deriving these nutritional requirements is a statistical probability concept that relates the
intakes to risk of deficiency and excess. Finally, the Recommended Dietary Allowances
(RDAs), and the Recommended Nutrient Intakes (RNIs), derived using the probability
concept was presented, intended to serve as goals for usual daily dietary intakes. The RDAs
for Indians by the Indian Council of Medical Research and the RNIs for the world
population by the FAO/WHO joint consultation are two important reference values that
must be remembered. For each nutrient, consideration was given to function, metabolism,
dietary intake patterns, requirement levels, and toxicity. Basal requirements, safe intake
levels, recommended dietary allowances, and tolerable upper intake levels are to be
established for each.
KEYWORDS
Apparently healthy- absence of disease based on clinical signs and symptoms of
micronutrient deficiency or excess, and normal function as assesses by laboratory methods
and physical evaluation.
Bioavailability- the percent of the dietary nutrient absorbed and utilized for a specific
function by the body.
Obligatory losses- the losses that occur when an individual is put on a diet free of any
particular nutrient.
REFERENCES
➢ Chadha, R., & Mathur, P. (2015). Nutrition: A Lifecycle Approach. 1st Ed. Orient
BlackSwan.
27
➢ FAO Nutrition Meetings Report Series, No. 52; WHO Technical Report Series, No.
522, 1973 (Energy and protein requirements: Report of a Joint FAO/WHO Ad Hoc
Expert Committee).
➢ Byrd-Bredbenner, C.,G. Moe, D. Beshgetoor, and J.Berning, Wardlaw’s
Perspectives in nutrition. 9th Ed. New York: McGraw-Hill International Edition,
2013.
28
LESSON 3
INTRODUCTION TO MEAL PLANNING
INTRODUCTION
Healthy eating is one of the key components of healthy living. Therefore it is essential to
plan and prepare balanced meal to cater to the nutritional requirements of individuals. Meal
planning is the planning of meals for all members of the family in order to provide
nutrition on time according to their needs and choices. Meal planning thus is both an
art and a science. It is a science of selecting food on the basis of nutritive value to
provide optimum nutrition to all members of the family. It is an art of skilful blending
of colour, taste, flavour and texture in meals. As the family’s well-being and health are
dependent on how well they are fed. It is a challenge to every meal-planner to meet it and
when well done, it proves to be a satisfying and rewarding experience. Besides others
factors such as digestibility, palatability, economy, family customs, related to religion, food
fads etc., it also determines whether the food can be actually supplied and utilized by the
individual.
OBJECTIVES
After going through this lesson you will be able to
❖ Understand the importance of balanced diet for different age groups.
❖ Apply the concept of meal planning in day-to-day life.
❖ Plan meals for various age groups according to their specific nutrient requirements.
PRINCIPLES OF MEAL PLANNING
The planned food needs to be tasty and palatable with its nutritive value. Every individual
desires that the food prepared by them should not only provide satiety but also give mental
satisfaction. For this purpose following principles are to be followed during meal planning:
▪ Satisfy the nutritional needs of the family members- A family may have
members of all age groups like infant, adolescent, adult, pregnant lady, elderly etc.
nutritional needs of each member may differ. Hence it is necessary to consider the
daily nutritional requirement of each member. It is also important to include foods
from each food groups. Food selected from only one food group are neither
nutritionally balanced nor likeable.
▪ Meal pattern must suit the family- To take into account the food preference of
individual members.
▪ Should economize time, fuel, money and energy- This can be done by preparation
of food, using time and labour saving devices or by arranging kitchen
systematically.
29
▪ Meals should provide satiable value- Any individual meal should provide enough
satiety value, so that one does not feel hungry till it is time for the next meal.
Proteins and fats have greater satiety value as compared to carbohydrates e.g. a
breakfast of just tea and toast will not provide enough satiety value till lunch,
whereas, a breakfast of milk, cereal, eggs and fruit will provide enough satiety value
till lunch.
▪ Variety in meals- Nobody like a rigid meal pattern every day. Variety in food is a
must so that all members of the family can enjoy it. This can be done by
o Selecting different foods from various food groups
o By blending colour, taste, texture and flavour into it
o By using different methods of cooking
SIGNIFICANCE OF MEAL PLANNING
The meal planning helps to make the best use of the material, time and financial resources,
to obtain meals that meet the physical, social and psychological needs of the individual and
families.
▪ Balanced diet to all family members- It is very important to plan family meals in
order to fulfil the nutritional requirement of the family members. This is essential
to keep them strong, healthy, and free from any disease and deficiency of any kind.
▪ Saves time, money and energy- Meal planning is of utmost importance because it
economizes on time, labour and fuel. While planning meals, the methods of
working can be carefully thought out, so that there is maximum retention of
nutrients and minimum losses.
▪ Control on food budget- Meals can be planned according to the budget of the
family. There can then be maximum utilization of money, if it is spent in the best
possible way. One can have a rich diet without buying expensive foods.
Meal planning therefore encourages one to plan within the family means.
▪ Provides variety in meals- Meal planning allows one to select different foods from
the same food group and avoid monotony. Besides, use of variety of foodstuffs is
important from nutritional point also.
▪ Use of left overs- By planning meals leftovers can be used properly, e.g. leftover
dal or dry vegetables at dinner can be used in parathas and patties in breakfast.
▪ Meal planning determines the adequacy of the diet, the kinds of foods purchased,
its quality and cost, the way it is stored, prepared and served.
▪ Tasty and attractive food- By adding variety to the taste, colour, texture and
cooking methods monotony in food can be broken and members can relish the food.
30
CHARACTERISTICS OF A WELL-PLANNED MEAL
▪ First of all it should be remembered that food has to be palatable before it can
become nutritious, as majority of people will not eat something they do not like,
even if it has excellent nutritive value.
▪ We should remember that appetite is the pleasurable anticipation of foods and
depends not only on hunger but also on taste, texture, appearance and attractiveness
of the foods, pleasantness of the surrounding and a cheerful frame of mind.
STEPS IN MEAL PLANNING
FACTORS AFFECTING MEAL PLANNING
Meal planning whether for the simplest family meal or for an elaborate company dinner,
involve consideration of a number of factors. These are:
1. Nutritional adequacy – Meal pattern must fulfil the family needs, so that the
nutrition requirement of each individual in the family are met. These requirements
differ from person to person according to age, sex, activity and physiological
condition, therefore, due consideration should be given to each member of the
Decide the nutritious menu with tasty and appealing recipes
Decide the meal pattern and distribute the food exchanges according to the meal pattern
Check if % of energy from carbohydrates, protein and fats are as per recommendations
Check if nutrient content has been met.
Decide on total exchanges for each food group
Calculate the nutrient requirements
Identify the individual characteristics like age, sex, activity level, income, physiological condition etc
31
family. The best way to ensure nutritional adequacy of a diet is to select the food
from all the five food groups.
The different requirement for different family members does not mean that separate
cooking is to be done for all of them. But the diet can be planned in such a way that
while cooking the same food, the nutritional requirements of all the members can
be catered e.g. by increasing or decreasing the amount of certain foodstuffs, by
including some extra protein food for growth periods etc. For instance, the same
salad can be used for both the overweight and the underweight members of the
family if the dressing is omitted for the former.
2. Economic factor-The amount of money available, depending upon the socio-
economic status also effects the meal planning. The major part of the income is
spent on food. Therefore, one should spend economically to get maximum
utilization. Although the budget of a family of middle-income group may not
provide for foods of the luxury class, it can still offer variety and opportunity for
choice. Food budgets in lower income families permit even more limited choice
and it may become increasingly necessary to depend on cereal foods for the main
or substantial part of the meal. Then the problem faced is the supplementation
of these cereals with foods necessary for a balanced diet. Although it may become
difficult to plan, it is nevertheless possible. Thereby, it is very important to know
the less expensive alternative for the more expensive recommended foods, having
high nutritive value. Such recipes and foods should be included in meal preparation
like using cereal-pulse combination e.g. khichri, paustik roti, seasonal vegetables,
butter milk, jaggery, pickle and chutney.
3. Availability of time, energy and labour saving devices- Meal planning is greatly
affected by availability of time, energy and labour saving devices. This is important
in cases of working women. Time like money needs to be budgeted for its best use.
Such women usually like cook simple meals which can be prepared easily; and
quickly.
4. Likes and dislikes- Although the recommended dietary allowances for each of the
classes of food should be followed, there is room for individual preference amongst
the foods in each class. Some people make personal likes and dislikes the only basis
for the inclusion or exclusion of certain foods in their meals – the failure to include
milk is a common practice. It is always better to change the form of the food rather
than to completely omit it. For example, milk can be given in the form of curd,
cheese, custard or other sweet dish; soyabean in the form of soya flour chapattis
mixed with wheat flour.
5. Religion, traditions and customs- They are important in determining the food
included in the diet, type of meal and the dishes served to the individual of family.
For instance, Muslims don’t eat pork, whereas Hindus do not eat beef. Rice is
considered an auspicious dish at festivals and marriages. Widows are generally not
32
served fish in Bengal. Therefore, religion, traditions and customs should be kept in
view while planning meals for a family.
6. Food fads and fallacies- It often receives more publicity than sound nutrition
information. Therefore, while planning the meals, one must try and remove these
foods fads, so that nutritious meals are provided.
7. Food availability- In earlier times, the dietary habits depended mainly upon the
foods produced in a particular area or community, but today with improved methods
of food preservation and distribution, even the most perishable foods are available
over large areas. The wide variation in dietary patterns throughout the world
depends largely upon the available food supply.
8. Climate and weather conditions- Meals should be in accordance with the season.
With the change in season the food availability and taste also change Thereby, it is
advisable to include seasonal foods in the diet. Also, the season of the year requires
some consideration, for the type of dishes selected e.g. inclusion of hot soups etc.
in cold winter days and chilly salads and juices in summers.
9. Variety- It is very important, because nobody likes to eat even his favourite food
stuff over and over again. Therefore, to introduce variety, do not repeat same food
items during day meal. Also variety in meal planning is the sum total of many kinds
and classes of food served in - pleasing colour combinations, with judicious mixture
of soft and crisp foods, blunt and sharp flavours, hot and cold dishes. It ensures
better nutrition and also results in more interesting meals with an attractive variety
of texture, colour, taste and appearance which in turn stimulates appetite and
pleases the palate. Various methods of cooking can also introduce a variety – a meal
consisting of tandoori roti, dal and seasonal green vegetable also with a crisp salad.
10. Lifestyle- Each family has a different lifestyle. While planning meals, one needs to
think of the schedules (time table) of the family members – meal times and the
number of meals eaten at home and those that are eaten away from home. If packed
lunches are made, the menus need to be modified to ensure that the items can be
packed and the menu is appetizing even when cold. The meals should be planned
according to the time for meal i.e. whether it is breakfast, lunch or dinner. Normally
while planning the meal for whole day, it is seen that 1/3rd of day’s requirement
are met by lunch, 1/3rd by dinner and 1/3rd by breakfast and evening tea. But this
is not a rigid schedule and can be changed according to individual requirement, as
long as the total nutritional requirements are being met.
11. Size and composition of the family
i. Size of the family - Size of a family refers to the number of its members. Amount
of food served in the family is largely determined by the number of its members.
More members mean more food for the family. It is known that the money
spent for food per person decreases as the family size increases, when the family
income remains constant. Staples such as wheat and rice are bought in larger
33
amounts but quantity of milk, vegetables and fruits is lowered. Thus, the quality
of the diet is affected.
ii. Family composition - Family composition refers to the age, sex, activity,
occupation, and different physical conditions of its members. Family
composition affects the kind and amounts of food needed and pattern of meals
served.
• Age- Age determines the nutritional requirements of all family members.
When children are below 5 years of age, more milk is required, the numbers
of meals are more, as the child cannot take large amount at a time. As the
child grows the meal pattern changes to accommodate the school hours and
the need to pack lunch or snack may arise. Older members of the family
may require change in consistency of food due to dental problems.
• Sex- Normally women require less food as compared to men because of their
less height, weight, body composition, and physical activity, e.g., a 30
years-old woman doing heavy work requires 2850 calories per day but the
requirement of a male of the same age and doing the same work requires
3490 calories per day.
• Physical condition-Some specific body conditions affect the nutritional
requirements, e.g., during pregnancy and lactation the body requires more
nutrients.
12. Occasion- For daily meals the first importance is given to nutritive value. However,
for special occasion, special importance has to be given to colour, appearance,
number of dishes to be included, but at the same time nutritive value cannot be
ignored. Similarly each festival has its specific food item which should always be
given importance e.g. preparing sweets for Deepawali, cake for Christmas, sewiyan
for Eid etc.
Points to remember while planning nutritionally adequate meals
• Consider whole day as a unit rather than individual meals.
• Try to distribute carbohydrates, fats and proteins throughout the day, so that no meal
has predominance of any kind of food stuff or nutrient.
• Always include vegetables and fruits in all your meals to add a dose of vitamins and
minerals, because it helps in better absorption of other nutrients.
• Since cereal is a staple, it should be included in all the meals of the day.
• Use seasonal foods because they are best in flavour and cheap, however, avoid giving
the same food stuff and especially in the same meal e.g. don’t give tomato soup, tomato
macaroni and tomato salad for the same meal. But, during the day things like cereals,
butter, milk has to be repeated.
• Take care of colour, flavour and texture by giving contrast in each meal e.g. keep the
colour combination of dishes in mind while planning the meal. The dishes can be
garnished to bring about more colour in diet. Flavour of food should be blended with
34
each other. There should also be some contrast in texture e.g. some dishes can be soft
and some dishes can be crisp, like with the soup we can give toasted bread etc.
• There should be a balance between the dishes like some dishes should be light and some
should be heavy e.g., filling soup can be served with light main meal and vice-versa.
• Include the favourite foods of the family at different meals, but at the same time don’t
be limited to only these foods and try to introduce new dishes, so that food habits can
be expanded.
USE OF FOOD EXCHANGE LIST FOR MEAL PLANNING
STEP 1: MAKE A FOOD PLAN
The food plan consists of the total number of exchanges of each of the seven food groups,
consisting the food exchange system, which fulfil the given nutritional requirements.
Preparation of the Food Plan includes assessing the approximate amounts of milk, meat
and pulse that a person can afford, depending on the socio economic status and preferences,
which will provide most of the protein requirements and part of the energy requirements.
Sufficient amount of vegetable and fruit are also included based on economic status and
preferences to ensure adequacy of vitamins in the diet. The energy and protein values
provided by milk, meat, pulse, vegetables and fruit are calculated. The remaining energy
requirement is then provided by cereal exchange, fat exchange and sugar. The cereal
exchange should also provide remaining amount of required proteins. As far as possible,
food exchanges should be in the whole numbers.
STEP 2: PREPARATION OF MEAL PATTERN
It involves distributing the food exchanges from the total food plan, as evenly as possible,
between the various meals. This ensures balance of nutrients between the meals and
nutritional adequacy of the meal.
STEP 3: CREATE A MENU PLAN
This step involves translation of food allowances in the meal pattern into a menu plan
suitable for the individual. This method of meal planning can be used for low, medium or
high cost diets by
▪ Adjusting the amount of different food exchanges used providing the same nutrient
content
▪ By selecting suitable foods with in the an exchange
The detailed exchange list of each food group permits easy substitution of foods, thus
adding flexibility, interest, variety and ease in meal planning. While menu planning with
its detailed nutrient composition, it is advisable to calculate the nutrient intake of each meal
besides the total day’s nutrient intake.
Further, to judge the adequacy of diet in terms of various nutrients, it is treated for detailed
calculations. For this purpose, food composition tables are used which give the nutritive
35
value of several food stuffs per 100 gram of the edible portion (IFCT, 2017). Generally
detailed calculations are done for three important nutrients – 1st for energy, then 2nd is for
protein and the 3rd important nutrients is variable depending upon the requirements for the
individual for whom the diet is planned.
General Considerations
a. The subject is a moderate worker, so his RDA is taken accordingly and the diet
should be nutritionally balanced.
b. One’s traditions, customs and beliefs should be kept in mind.
c. One’s likes and dislikes should be kept in mind.
d. The third important nutrient for the subject is thiamine, as thiamine’s allowances
are related energy intake i.e. to carbohydrate utilization.
e. Variety in the menu is essential and it should be provided in forms of colour, texture
and flavour.
f. Food items included should be of moderate cost with the inclusion of seasonal fruits
and vegetable etc. hereby economic factor is also kept in mind.
g. The planned meal should be able to provide enough satiety value.
h. Planned diet should be according to the climate and availability of food should be
kept in mind.
i. The meal should be served in a pleasant atmosphere.
LET’S CHECK THE PROGRESS
1. ‘Meal planning is both an art and a science’. Explain.
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
2. What are the objectives of meal planning?
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
3. How does lifestyle affect meal planning?
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
4. Explain how a family having limited economic resources can plan a nutritionally
balanced meal?
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
36
5. Why do we need to plan meals in advance?
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
SUMMARY
Meal planning involves planning diets which will provide all nutrients in required amounts
and proportions i.e. adequate nutrition. The amount and type of food to be consumed
depends on our age, gender, physical activity and physiological state. A food guide pyramid
is a visual guide to show the recommended intake for each food group. Planning meals
helps to ensure that the nutritional needs or all the members are adequately met. It also
saves time, money and fuel used in food preparation. It is important to incorporate variety
in meals in terms of colour, texture and taste to make it more appetising.
KEY WORDS
Adequacy- providing all essential nutrients in sufficient amounts.
Convenience food- a pre-prepared commercial food that requires minimum further
preparation at consumer level.
Food fad- diets that do not follow common nutritional guidelines.
Perishable foods- foods that get spoil easily, if not properly stores, due to high moisture
content.
Satiety- feeling of fullness after a meal.
REFERENCES
➢ Chadha, R., & Mathur, P. (2015). Nutrition: A Lifecycle Approach. 1st Ed. Orient
BlackSwan.
➢ ICMR. Nutritive Value of Indian Foods. Gopalan C, Rama Sastri BV,
Balasubramanian SC, Narasinga Rao BS, Deosthale YG, Pant KC. Indian Council
of Medical Research, National Institute of Nutrition, Hyderabad. 1999.
➢ NIN. Dietary Guidelines for Indians- A Manual. 2nd Ed., Hyderabad National
Institute of Nutrition. Indian Council of Medical Research, 2011.
➢ http://www.idoj.in/viewimage.asp?img=IndianDermatolOnlineJ_2013_4_4_358_
120688_t7.jpg
37
LESSON 4
DIETARY GUIDELINES FOR INDIANS
Humans need a wide range of nutrients to lead a healthy and active life. The required
nutrients for different physiological groups can only be derived from a well-balanced diet.
Components of the diet must be chosen judiciously to provide all the nutrients to meet the
human requirements in proper proportions for the different physiological activities. The
amount of each nutrient needed for an individual depends upon his/her age, body weight
and physiological status.
OBJECTIVES
After going through this lesson you will be able to
❖ Understand the relevance of dietary guidelines.
❖ Understand the dietary guidelines for Indians.
IMPORTANCE OF THE DIETARY GUIDELINES
Good nutrition is vital to good health and is absolutely essential for the healthy growth and
development of children and adolescents. Dietary guidelines are defined as a set of
guidelines or qualitative statements for making food choices that will help a person or a
population lead a healthy life, maintain optimum weight and reduce the risk of chronic
disease. They are based on nutritional targets such as recommended energy and nutrients
intakes, optimum weight and health targets such as prevention of chronic disease, control
of obesity and under nutrition. The Dietary Guidelines provides a framework to promote
healthier lifestyles. Given the importance of a balanced diet to health, the intent of
the Dietary Guidelines is to summarize and synthesize knowledge regarding individual
nutrients and food components into recommendations for an overall pattern of eating that
can be adopted by the general public. The Dietary Guidelines is applicable to the food
preferences of different racial/ethnic groups, vegetarians, and other groups. This concept
of balanced eating patterns should be utilized in planning diets for various population
groups. There is a growing body of evidence which demonstrates that following a diet that
complies with the Dietary Guidelines may reduce the risk of chronic disease.
A basic premise of the Dietary Guidelines is that nutrient needs should be met primarily
through consuming foods. Foods provide an array of nutrients (as well as phytochemicals,
antioxidants, etc.) and other compounds that may have beneficial effects on health. In some
cases, fortified foods may be useful sources of one or more nutrients that otherwise might
be consumed in less than recommended amounts. Supplements may be useful when they
fill a specific identified nutrient gap that cannot or is not otherwise being met by the
individual's intake of food. Nutrient supplements cannot replace a healthful diet.
Individuals who are already consuming the recommended amount of a nutrient in food will
38
not achieve any additional health benefit if they also take the nutrient as a supplement. In
fact, in some cases, supplements and fortified foods may cause intakes to exceed the safe
levels of nutrients. Another important premise of the Dietary Guidelines is that foods
should be prepared and handled in such a way that reduces risk of foodborne illness.
USES OF THE DIETARY GUIDELINES
The Dietary Guidelines is intended primarily for use by policymakers, healthcare
providers, nutritionists, and nutrition educators. Specific uses of the Dietary
Guidelines include:
• Development of Educational Materials and Communications
The information in the Dietary Guidelines is useful for the development of educational
materials. For example, the federal dietary guidance-related publications are required
by law to be based on the Dietary Guidelines. In addition, this publication will guide
the development of messages to communicate the Dietary Guidelines to the public.
Finally, the USDA Food Guide, the food label, and Nutrition Facts Panel provide
information that is useful for implementing the key recommendations in the Dietary
Guidelines and should be integrated into educational and communication messages.
• Development of Nutrition-Related Programs
The Dietary Guidelines aids policymakers in designing and implementing nutrition-
related programs. The Federal Government bases its nutrition programs, such as the
National Child Nutrition Programs or the Elderly Nutrition Program, on the Dietary
Guidelines.
• Development of Authoritative Statements
The Dietary Guidelines has the potential to provide authoritative statements as
provided for in the Food and Drug Administration Modernization Act (FDAMA).
Because the recommendations are interrelated and mutually dependent, the statements
in this publication should be used together in the context of an overall healthful diet.
Likewise, because the Dietary Guidelines contains discussions about emerging science,
only statements included in the Executive Summary and the highlighted boxes entitled
"Key Recommendations," which reflect the preponderance of scientific evidence, can
be used for identification of authoritative statements.
DEVELOPMENT OF FOOD-BASED DIETARY GUIDELINES
Food Based Dietary Guidelines are developed to advise the public on the types and
quantities of foods to consume in order to satisfy their nutritional requirements and prevent
disease. These guidelines (FBDGs) have been defined as science-based recommendations
in the form of guidelines for healthy eating. They are an attempt to translate a vast evidence
39
base regarding relations between foods, diet patterns, and health into specific, culturally
appropriate, and actionable recommendations. Such guidelines are intended to influence
consumer behavior and, in some countries, also inform a range of national food, nutrition,
and health policies and programs. The World Health Organization (WHO) advises
countries to develop guidelines based on the population structure and nutritional status as
well as the food commodities available and general consumption pattern in each country.
Development of FBDG is both a scientific and political process, incorporating a range of
evidence and stakeholder perspectives. The types of evidence used to inform FBDG
include: assessments of food and nutrient intakes, food supplies, prevalence and public
health importance of diet-related health and nutrition outcomes, cultural preferences, and
other considerations. Since the 1998 publication of Preparation and use of food-based
dietary guidelines based on a joint WHO/FAO consultation, many countries and regions
have developed their own national guidelines, often in partnership with, or facilitated by,
international agencies and bodies.
The development of FBDGs may be carried out using a stepwise approach as suggested by
FAO–WHO and the European Food Safety authority (EFSA): the identification of diet–
health relationships; identification of country specific diet-related health patterns and
problems; and disease and mortality patterns should be reviewed to identify public health
and nutrition priorities and key nutrients.
Country-specific health statistics and information systems are the basics at this step. Other
sources such as the Global Burden of Disease Study can be very useful as well, since it is
the most comprehensive worldwide study describing mortality and morbidity from major
diseases, injuries, and risk factors related to health at global, regional, and national levels.
In this step, nutrient imbalances in population subgroups should be identified by thorough
analysis of the best-quality evidence in the country on usual nutrient intakes and nutritional
status in the population: identification of food sources relevant for FBDGs, food
consumption patterns, as well as population characteristics for each pattern.
Recommendations in FBDGs should consider the specific needs of population groups and
be country specific. Testing and updating FBDGs and the best way to disseminate them is
also a key step in this process. In this sense, graphical representations of FBDGs are often
developed in order to facilitate communication to consumers.
ISSUES TO BE CONSIDERED IN IMPLEMENTING DIETARY GUIDELINES
FBDG’s should be scientifically sound. However, there are a number of other factors that
should be considered as well. To make the dietary guidelines meaningful to the general
public, they should be short, simple, clear, memorable, and culturally appropriate and
communicated well in a variety of media. Ideally, they should be multimedia and
40
multisectoral, address all relevant community groups and ages, and complement existing
community programmes.
• Practicality
The dietary guidelines should be practical for the general public to implement or else
they will not be used. That is, the recommended foods or food groups should be
affordable, widely available, and accessible to most people in the country taking into
account geographical variation. In addition, the guidelines should be flexible, that is
suitable for people of different ages (youth to old age), energy requirements (sedentary
to active), and in some cases physiological states (e.g. pregnancy and lactation).
• Comprehensibility
Dietary guidelines will fail if they are not understood by the general public. Reading
level of the document and advice should be kept to a 5th or 6th grade level (or 4-5 years
of primary education) whenever possible, in industrialized countries. In many other
countries, much lower levels of literacy should be assumed or even non-literacy. In
addition, the terminology should represent both everyday usage and scientific meaning,
which can be problematic. For example, the public may misinterpret words such as
"fat" (thinking it is only visible fats in foods or not including oil), or "too much", or
"moderation", or "avoid too much". If the public does not understand the dietary
guidelines, they will either dismiss them or misapply the advice due to misconceptions.
If food groups are incorporated into the dietary guidelines, the groupings should make
sense to the general public. Food groupings in dietary guidelines or accompanying
educational materials should complement the food classification systems used by the
target population. Visuals that illustrate the dietary guidelines should be readily
understood. Concrete illustrations are preferable to abstract visuals.
• Cultural acceptability
Dietary guidelines will fail if the public finds them culturally unacceptable. The most
important factors influencing acceptability are the current food habits and specific food
recommendations incorporated into a set of guidelines. For example, guidelines or food
group illustrations that promote meat among vegetarian populations will be rejected.
Food recommendations that violate religious prohibitions or propose radical changes
in current practices will be rejected. Recommendations for small changes and familiar
foods will be better accepted. Portion sizes, number of recommended servings, and
traditional food preparation techniques should also be considered. In terms of
presentation, dialect or language, illustrations (e.g. race or ethnicity of illustrated
models) and colour choice (e.g. colours that represent certain political parties or other
associations) can also affect the acceptability of a set of recommendations. The
communication channel may also be more culturally acceptable, or less so. Therefore,
41
the choice of who conveys the message (are they credible?) and how they deliver the
message (is it readily accessible and accepted?) should also be considered in a cultural
context. Variations in educational level and rural versus urban needs may need to be
addressed as well. Again, evaluation and revision of dietary guidelines among the
intended users are essential to meet cultural acceptability.
DIETARY GOALS
a. Maintenance of a state of positive health and optimal performance in populations
at large by maintaining ideal body weight.
b. Ensuring adequate nutritional status for pregnant women and lactating mothers.
c. Improvement of birth weights and promotion of growth of infants, children and
adolescents to achieve their full genetic potential.
d. Achievement of adequacy in all nutrients and prevention of deficiency diseases.
e. Prevention of chronic diet-related disorders.
f. Maintenance of the health of the elderly and increasing the life expectancy.
DIETARY GUIDELINES
Formulation of dietary goals and specific guidelines would help in providing required
guidance to people in ensuring nutritional adequacy. The dietary guidelines could be
directly applied for general population or specific physiological or high risk groups to
derive health benefits. They may also be used by medical and health personnel, nutritionists
and dietitians. The guidelines are consistent with the goals set in national policies on
Agriculture, Health and Nutrition. The dietary guidelines ought to be practical, dynamic
and flexible, based on the prevailing situation. Their utility is influenced by the extent to
which they reflect the social, economic, agricultural and other environmental conditions.
The guidelines can be considered as an integral component of the country's comprehensive
plan to reach the goals specified in the National Nutrition Policy.
According to NIN, “The shift from traditional to 'modern' foods, changing cooking
practices, increased intake of processed and ready-to-eat foods, intensive marketing of junk
foods and health beverages have affected people's perception of foods as well as their
dietary behaviour. Irrational preference for energy-dense foods and those with high sugar
and salt content pose a serious health risk to the people, especially children.” The new
guidelines, putting it in a nutshell has proposed a reduction in the total requirements in
terms of carbohydrates, salt, sugar and fats. The transition is in the increase in protein intake
to ensure good muscle build up.
DIETARY GUIDELINES FOR INDIANS
Right nutritional behavior and dietary choices are needed to achieve dietary goals.
The following 15 dietary guidelines provide a broad framework for appropriate
action:
42
• Eat variety of foods to ensure a balanced diet.
• Ensure provision of extra food and healthcare to pregnant and lactating women.
• Promote exclusive breastfeeding for six months and encourage breastfeeding till
two years or as long as one can.
• Feed home based semi solid foods to the infant after six months.
• Ensure adequate and appropriate diets for children and adolescents, both in
health and sickness.
• Eat plenty of vegetables and fruits.
• Ensure moderate use of edible oils and animal foods and very less use of ghee/
butter/ vanaspati.
• Avoid overeating to prevent overweight and obesity.
• Exercise regularly and be physically active to maintain ideal body weight.
• Restrict salt intake to minimum.
• Ensure the use of safe and clean foods.
• Adopt right pre-cooking processes and appropriate cooking methods.
• Drink plenty of water and take beverages in moderation.
• Minimize the use of processed foods rich in salt, sugar and fats.
• Include micronutrient-rich foods in the diets of elderly people to enable them to
be fit and active.
1. Eat variety of foods to ensure a balanced diet - Eating a healthy, balanced diet is an
important part of maintaining good health, and can help you feel your best. This means
eating a wide variety of foods in the right proportions, and consuming the right amount
of food and drink to achieve and maintain a healthy body weight. Opting for a balanced,
adequate and varied diet is an important step towards a happy and healthy lifestyle.
Healthy diets can also contribute to an adequate body weight. Healthy eating is a good
opportunity to enrich life by experimenting with different foods from different cultures,
origins and with different ways to prepare food. The benefits of eating a wide variety
of foods are also emotional, as variety and colour are important ingredients of a balance
diet. Choose a variety of foods in amounts appropriate for age, gender, physiological
status and physical activity. Use a combination of whole grains, grams and greens.
Include jaggery or sugar and cooking oils to bridge the calorie or energy gap. Prefer
fresh, locally available vegetables and fruits in plenty. Include in the diets, foods of
animal origin such as milk, eggs and meat, particularly for pregnant and lactating
women and children. Adults should choose low-fat, protein-rich foods such as lean
meat, fish, pulses and low-fat milk. Develop healthy eating habits and exercise
regularly and move as much as you can to avoid sedentary lifestyle.
2. Ensure provision of extra food and healthcare to pregnant and lactating women -
Pregnancy and lactation are demanding physiological states of the body, both
physiologically and nutritionally Nutrition is of paramount importance for the health
43
and development of mothers and their new-born children. In both the condition,
requirements of energy, protein, and essential micronutrients (vitamins and minerals)
are increased not only to maintain the mother’s own health, but to also support optimal
physical and brain development in the foetus. Good quality protein is derived from
milk, fish, meat, poultry and eggs. However, a proper combination of cereals, pulses
and nuts also provides adequate proteins. Mineral and vitamin requirements are met by
consuming a variety of seasonal vegetables particularly green leafy vegetables, milk
and fresh fruits. Bioavailability of iron can be improved by using fermented and
sprouted grams and foods rich in vitamin C such as citrus fruits. Milk is the best source
of biologically available calcium. Though it is possible to meet the requirements for
most of the nutrients through a balanced diet, pregnant/lactating women are advised to
take daily supplements of iron, folic acid, vitamin B and calcium. Deficiencies of
energy, protein, iron, calcium, iodine, vitamin A and folic acid during pregnancy
predispose mothers to maternal complications and even mortality. These also
contribute to foetal birth defects, low birth weight, restricted physical and mental
potential, and foetal or new-born mortality.
3. Promote exclusive breastfeeding for six months and encourage breastfeeding till
two years or as long as one can - Breast-milk is the most natural and perfect food for
normal growth and healthy development of infants. Colostrum is rich in nutrients and
anti-infective factors and should be fed to infants. Breast-feeding reduces risk of
infections. It establishes mother-infant contact and promotes mother-child bonding. It
prolongs birth interval by fertility control (delayed return of menstruation). Breast
feeding is associated with better cognitive development of children and may provide
some long-term health benefits. Start breast-feeding within an hour after delivery and
do not discard colostrum. Breast-feed exclusively (not even water) for a minimum of
six months if the growth of the infant is adequate. Continue breast-feeding in addition
to nutrient-rich complementary foods (weaning foods), preferably up to 2 years. Breast-
feed the infant frequently and on demand to establish and maintain good milk supply.
4. Feed home based semi solid foods to the infant after six months - Adequate nutrition
during infancy and early childhood is fundamental to the development of each child’s
full human potential. It is well recognized that the period from birth to two years of age
is a “critical window” for the promotion of optimal growth, health and behavioural
development. Practice exclusive breastfeeding from birth to 6 months of age, and
introduce complementary foods at 6 months of age (180 days) while continuing to
breastfeed. Breast milk alone cannot supply the nutritional needs beyond 6 months of
infant’s life and therefore, supplementary foods are needed. It is generally seen that till
6 months the infants thrives well on mother’s milk and it is only after that if adequate
supplements are not fed, the infant shows signs of inferior growth development, and
symptoms of under-nutrition.
44
“The process of introducing supplementary foods along with the mother’s milk
to an infant is known as weaning or supplementary feeding”.
This is a gradual process. It starts when supplementary foods are introduced to the child
and continues until the child stops taking breast milk all together. Any other food except
mother’s milk is known as supplementary food.
Weaning is the process of gradually introducing foods other than breast milk in the
child’s feeding schedule. This process starts with any food besides mother’s milk. It is
introduced in the child’s diet and is completed only when the child has been entirely
put off the breast. It has two advantages, firstly, it meets the increased energy and
nutritional requirements for the infants after 6 months and secondly, it makes the infant
gradually accustomed to new tastes and textures of different food, which helps the
infant to adjust to family food in early childhood and, thereafter. By the time the child
is a year old, he should get used to the normal family diet. To address the issue of a
small stomach size which can accommodate limited quantity at a time, each meal must
be made energy dense by adding sugar/jaggery and ghee/butter/oil. To provide more
calories from smaller volumes, food must be thick in consistency; thick enough to stay
on the spoon without running off, when the spoon is tilted.
5. Ensure adequate and appropriate diets for children and adolescents, both in
health and sickness - Childhood and adolescence are critical periods for health and
development as the physiological need for nutrients increases and the consumption of
a diet of high nutritional quality is particularly important. Eating habits, lifestyle and
behaviour patterns are established during this period that may persist throughout
adulthood. A healthy diet during childhood and adolescence reduces the risk of
immediate nutrition related health problems of primary concern to school children,
namely obesity, dental caries and lack of physical activity. In addition, young people
who healthy eating habits developed early in life are more likely to maintain them and
thus be at reduced risk of chronic ailments such as cardiovascular diseases, cancer, type
II diabetes and osteoporosis in adulthood.
6. Eat plenty of vegetables and fruits - Vegetables and fruits are an important part of a
healthy diet, and variety is as important as quantity. Fruits and vegetables contain
important vitamins, minerals and plant chemicals. They also contain fibre. Vegetables
are important sources of many nutrients, including potassium, dietary fibre, folate (folic
acid), vitamin A, and vitamin C. Diets rich in potassium may help to maintain healthy
blood pressure. Vegetable sources of potassium include sweet potatoes, white potatoes,
white beans, tomato products (paste, sauce, and juice), beet greens, soybeans, lima
beans, spinach, lentils, and kidney beans. Dietary fibre from vegetables, as part of an
overall healthy diet, helps reduce blood cholesterol levels and may lower risk of heart
disease. Fiber is important for proper bowel function. It helps reduce constipation and
diverticulosis. Fiber-containing foods such as vegetables help provide a feeling of
fullness with fewer calories. Folate (folic acid) helps the body form red blood cells.
45
Women of childbearing age who may become pregnant should consume adequate folate
from foods, and in addition 400 mcg of synthetic folic acid from fortified foods or
supplements. This reduces the risk of neural tube defects, spina bifida, and anencephaly
during foetal development. Vitamin A keeps eyes and skin healthy and helps to protect
against infections. Vitamin C helps heal cuts and wounds and keeps teeth and gums
healthy. Vitamin C aids in iron absorption. A diet rich in vegetables and fruits can lower
blood pressure, reduce the risk of heart disease and stroke, prevent some types of
cancer, lower risk of eye and digestive problems, and have a positive effect upon blood
sugar, which can help keep appetite in check. Eating non-starchy vegetables and fruits
like apples, pears, and green leafy vegetables may even promote weight loss.
7. Ensure moderate use of edible oils and animal foods and very less use of ghee/
butter/ vanaspati - Fats and oils like vegetable oils, vanaspati and ghee are dense
sources of energy. One gram of fat provides 9 Kcal. It is mostly used as the cooking
medium and hence form a necessary part of the diet of all section of the society. Fats
also promote the absorption of the four fat-soluble vitamins (A, D, E and K), impart a
feeling of fullness and satisfaction and thus, delay the onset of hunger. It helps to
increase the palatability of our food. Fats are essential for meeting some of the
nutritional needs like essential fatty acids (linoleic n-6 and alpha-linolenic n-3) and
serve as rich sources of energy. Therefore, fats should be consumed, in moderation.
Dietary fats can be derived from plant and animal sources. Fats that are used as such at
the table or during cooking (vegetable oils, vanaspati, butter and ghee) are termed as
“visible” fats. Fats that are present as an integral components of various foods are
referred to as “invisible” fat. Fats/oils have high energy value and induce satiety. Diets
that provide excess of calories, fats and cholesterol elevate blood lipids (cholesterol and
triglycerides) and promote blood clotting. Excessive fat in the diet increases the risk of
obesity, heart disease, stroke and cancer. Saturated fatty acids are known to increase
serum total and LDL-cholesterol levels, reduce insulin sensitivity and enhance
thrombogenicity and increase CVD risk. Therefore, SFA intake should not exceed 8-
10% of total energy. Skimmed milk should be preferred instead of whole milk. Restrict
consumption of butter and cheese.
8. Avoid overeating to prevent overweight and obesity-Overweight/obesity is the
causative factor for several chronic non-communicable diseases including heart
disease, diabetes and certain types of cancers. Definition of obesity is based on the
degree of excess fat. More than a general accumulation, the distribution of fat around
the abdomen is now considered to be more harmful than fat around the hips.
Accumulation of fat around abdomen indicated by higher waist circumference is
considered as risk factor. In general, BMI ranging from 18.5 to 25 is considered to be
normal. However, for Asians it is recommended that the BMI should be between 18.5
and 23, since, they tend to have higher percentage body fat even at lower BMI
compared to Caucasians and Europeans, which puts them at higher risk of chronic non-
46
communicable diseases. The cut-off levels for categorizing overweight and obesity in
children and adolescents are different. Since, growth spurt in boys and girls occurs in
different age groups, age and gender specific BMI centiles of reference population is
used to assess their nutritional status. Thus, children with BMI less than 5th centile are
considered as undernourished and those with =5th and <85th centiles are normal, and
with =85th and <95th centile are considered as overweight. More than 95th centile are
considered as obese. There are several health consequences of obesity. Excessive body
weight increases the risk of heart disease, hypertension, diabetes, gallstones, certain
types of cancers and osteoarthritis. Obesity invariably predisposes to reduced levels of
high density lipoproteins ('good' cholesterol) and to increased levels of low density
lipoproteins ('bad' cholesterol), and triglycerides, besides an abnormal increase in
glucose and insulin levels in blood. Considering the increasing trend in the prevalence
of coronary artery disease, hypertension and diabetes in India, it is important to
maintain desirable body weight for height and avoid obesity.
9. Exercise regularly and be physically active to maintain ideal body weight-Physical
activity is an essential component for the management of many health conditions. It
also has a major impact on the health of an individual. It is defined as “any bodily
movement produced by skeletal muscles that require energy expenditure”. It includes
exercise as well as other activities which involve bodily movement and is done as part
of playing, working, active transportation, household chores and recreational activities.
Physical inactivity is one of the behavioural risk factors for NCDs are becoming a major
public health concern. It is causing an estimated 3.2 million deaths globally. It has also
been associated with the risk of several chronic diseases and health conditions like
cardiovascular diseases, diabetes, hypertension, colon and breast cancer, depression
and also obesity. There is convincing evidence that regular physical activity is
protective against unhealthy weight gain whereas sedentary lifestyles, particularly
sedentary occupations and inactive recreation such as watching television, promote it.
According to ICMR 2010, at least 45 minutes of physical activity of moderate intensity for
at least 5 days in a week is recommended. To lose weight, the recommendations suggest at
least 60 minutes of moderate-to vigorous-intensity physical activity on most days of the
week. Those, who are on low-calorie diets for body weight reduction should have moderate
to vigorous intensity physical activities at least for 60-90 minutes daily. Adults over the age
of 20 years should undertake a minimum of 30-45 minutes of physical activity of moderate
intensity (such as brisk walking 5-6 km/hr) 5-6 days of the week. An exercise program should
include 'warm up' and 'cool down' periods each lasting for 5 minutes. During exercise, the
intensity of exercise should ensure a 60-70% increase in heart rate.
According to WHO 2010, for adults of 18-64 years of age, physical activity can take
place in different domains which includes recreational or leisure-time physical activity,
transportation (e.g. walking or cycling), occupational (i.e. work), household chores, play,
47
games, sports or planned exercise, in the context of daily, family, and community
activities. In order to improve cardiorespiratory and muscular fitness, bone health and
reduce the risk of NCDs and depression the following are recommended:
• Adults aged 18–64 years should do at least 150 minutes of moderate-intensity
aerobic physical activity throughout the week, or do at least 75 minutes of vigorous-
intensity aerobic physical activity throughout the week, or an equivalent
combination of moderate- and vigorous-intensity activity.
• Aerobic activity should be performed in bouts of at least 10 minutes in duration.
• For additional health benefits, adults should increase their moderate-intensity
aerobic physical activity to 300 minutes per week, or engage in 150 minutes of
vigorous-intensity aerobic physical activity per week, or an equivalent combination
of moderate- and vigorous-intensity activity.
• Muscle-strengthening activities should be done involving major muscle groups on
2 or more days a week.
10. Restrict salt intake to minimum - Salt is an essential ingredient of food and enhances
its taste. From time immemorial, it has been used as a preservative. All food substances
contain sodium, but added salt (sodium 40%, chloride 60%) is the major source of
sodium in our diet. Sodium is primarily involved in the maintenance of water balance
and equilibrium. It also plays an important role in electro-physiological functions of
the cell. Humans have powerful in-built mechanisms for maintaining blood pressure
even on minimal sodium intake. Sodium requirements depend on its losses through
urine, faeces and sweat. The sweat loss varies according to climatic conditions. High
ambient temperatures and vigorous physical exercise increase sodium loss through
sweat. Even after 6 hours of hard physical labour, which may generate 3 litres of sweat,
the requirement of sodium chloride may not be more than 6 g/day.
11. Ensure the use of safe and clean foods - Microbes (bacteria and moulds) and their
products are responsible for food spoilage. Natural enzymes present in food also lead
to its deterioration. Besides, insects, rodents, adulterants, natural toxins and various
chemical residues beyond permissible levels, make the food unwholesome. In addition
to moisture and environmental conditions like temperature, storage time also influence
the quality of the food. Selection of the right food is the first step to ensure safe and
good quality diet. Food items purchased from reliable sources having a high turnover
ensure their freshness. Some foods carry certification mark assuring good quality. For
example AGMARK for honey and ghee; FPO (Fruit Products Order) for fruit and
vegetable products (jams, squashes, etc); ISI (Bureau of Indian Standards) for food
colours and essences. While purchasing packaged food always look for ‘best before’ or
‘date of expiry’. Food grains purchased should be free from infestation and foreign
matter (rodent excreta and insect remains). They should be of uniform size and should
not be shrivelled, shrunken or mouldy. Foodstuffs should be free from artificial colours.
48
There is a risk of adulteration when fats/oils are purchased loose from unsealed
containers. Therefore, it is always safer to purchase reputed brand products in sealed
sachets/containers. It is necessary to buy pasteurized milk in sachets from a reputed
dairy or a reliable vendor to avoid the risk of adulteration and contamination.
12. Adopt right pre-cooking processes and appropriate cooking methods-Foods, in
their natural state, contain different nutrients in varying amounts. Cooking improves
the digestibility of most foods. Flesh foods get softened on cooking and become easily
chewable. Proper methods of cooking render foods palatable by improving the
appearance, taste, flavour and texture, thereby enhancing acceptability. In addition,
they help in destroying disease causing organisms and eliminating natural inhibitors of
digestion. In the course of food preparation, depending on the recipe, foods are
subjected to various processes such as washing, grinding, cutting, fermentation, and
germination and cooking. In the Indian cuisine, fermentation (idli, dosa, dhokla) and
germination (sprouting) are common practices. These methods improve digestibility
and increase nutrients such as B-complex vitamins and vitamin C.
13. Drink plenty of water and take beverages in moderation-The body's need for water
is only second to that of oxygen. One can live for weeks without food, but death is
likely to follow a deprivation of water for more than a few days. A 10% loss of body
water is a serious hazard and death usually follows at a 20% loss. About 70% of body
weight of lean adult is accounted for by water. Variations in the water contents in
different individual’s ae mainly due to differences in fat contents. In obese males, water
constitutes lower percentage to body weight (45-60%). All body tissues contain water
but variations in tissue contents are wide. Water performs number of functions in the
human body:
i. Part of structure- Water is a structural component and a cushion of all the
cells.
ii. Water is the medium of all body fluids including the digestive juice, the lymph,
the blood, the urine and the perspiration.
iii. Acts as solvent- Water is a solvent for the products of digestion, holding them
in solution and permitting to pass through the walls for absorption.
iv. Transport of nutrients-It is a carrier of nutrients as well as of waste.
v. Body temperature regulation-Water has the capacity to regulate the internal
temperature of the body in response to the external temperature. It helps in
maintaining the temperature of the body by distributing the heat in the body.
Sweat is the main means by which water prevents the human body overheating
when the temperature outside it is very high. The evaporation of sweat brings a
loss of calories, in the form of heat. This release of energy enables our internal
temperature to remain constant.
vi. Metabolic and biochemical reactions- Water is not just a transporter of
nutritional elements. It acts as a reactant and plays an active role in our
49
metabolic processes. Through a process called hydrolysis, water molecules are
part of the biochemical breakdown of proteins, lipids and carbohydrates, which
are structurally complex foods, into units more absorbable by the body.
vii. Acts as lubricant- Water is essential as a body lubricant. It is the main
constituent of saliva that makes swallowing possible, the mucus secretion of
gastrointestinal, respiratory and genitourinary tract, the fluids that bathe the
joints and so on.
14. Minimize the use of processed foods rich in salt, sugar and fats-Foods that are
subjected to technological modifications either for preservation or for converting into
ready-to-use/eat foods, eliminating laborious household procedures, are called
“processed foods”. Some of the examples are ready mixes, dehydrated foods, pasta
products, canned foods, confectioneries, bakery, dairy products and breakfast foods.
Increasing production of more and more processed food, rapid urbanization, and
changing lifestyles are transforming dietary patterns. Highly processed foods are
increasing in availability and becoming more affordable. People around the world are
consuming more energy-dense foods that are high in saturated fats, trans fats, sugars,
and salt. Processed foods being rich in fats, salt, sugar and preservatives may pose a
health risk if consumed regularly. Urbanization has increased the intake and demand
for processed foods. Limit consumption of sugar and unhealthy processed foods which
provide only (empty) calories.
15. Include micronutrient-rich foods in the diets of elderly people to enable them to
be fit and active - Nutrition offers the means to improve health and well-being and
among the predictive factors of successful aging, nutrition appears as one of the major
determinants. Whereas adequate nutrition plays a major role in a healthy lifestyle that
maintains bodily and mental functioning, inadequate nutrition contributes to a loss of
function and to the development and progression of disease. Body composition changes
with advancing age, and these changes affect nutritional needs of the elderly. Elderly
or aged people require reduced amounts of calories, as their lean muscle mass and
physical activity decrease with ageing. Elderly are more prone to diseases due to
lowered food intake, physical activity and resistance to infection. Good /healthy food
habits and regular comfortable level of physical activity are required to minimise the
ill effects of ageing and to improve the quality of life. Elderly need adequate amounts
of protein, carbohydrates, fat, vitamins, minerals and dietary fibre. Elderly need more
calcium, iron, zinc, vitamin A and antioxidants to prevent Age-related degenerative
diseases and for healthy ageing.
50
LET’S CHECK THE PROGRESS
1. Explain dietary guidelines and its uses.
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
2. What advice should be given to the elderly in order to remain healthy and physically
fit?
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------
3. Enlist the dietary guidelines covering all stages to of life?
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
4. Why cultural acceptability should be considered while implementing the dietary
guidelines?
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
SUMMARY
Food-based dietary guidelines are useful tools for preventive actions and health promotion
and are helpful for guidance in health, education, and community settings. These guidelines
are useful tools to convey clear and easy-to-understand messages to the general population
or for specific population groups, with the aim to facilitate the adoption of healthier dietary
patterns based on the best available evidence. As the body of evidence increases, social,
food consumption, and eating practices will also change under the influence of multiple
factors. This makes it necessary to periodically review and update FBDGs so that they are
operational and responsive to changing circumstances. In the case of using a representative
pictorial icon of the recommendations, this should be familiar, easily understandable, and
reflect the food reality of the country and prevalent eating habits.
FBDGs support the need to focus attention on food choices and mindful eating, as well as
to devoting adequate time to buying, preparing, and eating food with company whenever
possible.
The contents and recommendations in FBDGs must be in tune with the actual food,
cultural, gastronomic, and even economic context in order to propose changes in usual diets
that people can comfortably afford in the short and medium term, with the idea that it can
be maintained over time.
51
REFERENCES
➢ Chadha, R., & Mathur, P. (2015). Nutrition: A Lifecycle Approach. 1st Ed. Orient
BlackSwan.
➢ Food and Agriculture Organization. Preparation and Use of Food-Based Dietary
Guidelines. Report of a Joint FAO/WHO Consultation, Nutrition Programme, WHO,
Geneva, Switzerland 1996.
➢ EFSA Panel on Dietetic Products, Nutrition, and Allergies (NDA). Scientific Opinion
on establishing Food-Based Dietary Guidelines. EFSA J. 2010, 8, 1460.
➢ https://www.mdpi.com/2072-6643/11/11/2675/htm
52
53
UNIT 2
NUTRITION DURING THE ADULT YEARS
Lesson 5: Nutrition during Adulthood
Lesson 6: Nutrition during Pregnancy
Lesson 7: Nutrition during Lactation
Lesson 8: Nutrition for Elderly
54
55
LESSON 5
NUTRITION DURING ADULTHOOD
INTRODUCTION
With the onset of adulthood, good nutrition can help young adults enjoy an active lifestyle.
For most people, this is the time when their bodies are in the best condition. The body of
an adult does not need to devote its energy and resources to support the rapid growth and
development that characterizes youth. However, the choices made during those formative
years can have a lasting impact. Eating habits and preferences developed during childhood
and adolescence influence health and fitness into adulthood. Some adults have gotten a
healthy start and have established a sound diet and regular activity program, which helps
them remain in good condition from young adulthood into the later years. Others carry
childhood obesity into adulthood, which adversely affects their health. However, it is not
too late to change course and develop healthier habits and lifestyle choices. Therefore,
adults must monitor their dietary decisions and make sure their caloric intake provides the
energy that they require, without going into excess.
OBJECTIVES
After going through this lesson, you will be able to
❖ Summarize nutritional requirements and dietary recommendations for adults.
❖ Discuss the nutrition-related concerns during adulthood.
❖ Plan a meal for an adult by taking into consideration various factors.
ADULTHOOD
Adulthood, the period in the human lifespan in which full physical and intellectual maturity
have been attained. It represents the steady state in life when a person would have
completed his/her growth in terms of body size. People at this age do not have to include
nutrients for growth and strenuous activity of youth. The nutritional needs are for
maintenance of body functions. The energy needs in adults are mainly to sustain body
functions and activity. Adulthood also represents the productive stage of life. Therefore, it
is important that the nutritional needs of an adult be met adequately so as to keep vitality
and a positive attitude to life which is essential for optimum productivity. A good diet
fosters a vigorous maturity and can do much to delay the characteristics of old age.
Inadequate amount of certain nutrients in the diet in earlier years, if continued at this age,
may have serious repercussions. Therefore, good nutrition, as well as other health habits
should be adopted.
56
CHANGES ASSOCIATED WITH ADULTHOOD
At this time, growth is completed, and people reach their physical peak. Major organs and
body systems have fully matured by this stage of the life cycle. At this time, growth is
completed, and people reach their physical peak. Major organs and body systems have fully
matured by this stage of the life cycle. Though adulthood does not feature psychological
and social stress as in school age or adolescence, the family and social responsibilities of
the individual increases. This is when they tend to lead an independent living and many,
both men and women, are breadwinners for their family. Entry into married life adds to
their responsibilities, especially women who should be prepared to bear the physiological
stress during pregnancy and lactation. There may also be changes in lifestyle pattern based
on their occupation, which may change their eating habits. The physical and mental stress
due to their job, family and social pressure make adequate nutrition a necessity to safeguard
the health of this highly productive age group.
NUTRITIONAL REQUIREMENTS OF ADULTS
As mentioned earlier, the nutritional needs are mainly for maintenance of body functions
and to bear daily wear and tear. The requirements of different nutrients for adults are given
in Table 5.3 and since recommended dietary allowances for various nutrients cannot be
given for any individual person, ICMR has based the recommendations for adults in terms
of reference of Indian man and woman all discussed below (ICMR, 2010):
Reference Indian Man has been defined as “an adult man between 18-29 years of age,
weighing 60 kg with a height of 1.73m and a BMI of 20.3 kg/m2. He is free from disease
and is physically fit for active work. On each working day, he is engaged in eight hours of
occupation that usually involves moderate activity. While not at work, he spends eight
hours in bed, 4-6 hours in sitting and moving about and two hours in walking, active
recreation or household duties”.
Reference Indian Woman is defined as “an adult woman between 18-29 years of age, non-
pregnant, non-lactating (NPNL) weighing 55 kg with a height of 1.61m and a BMI of 21.2
kg/m2. She is free from disease and is physically fit for active work. She is engaged for
eight hours of occupation, which usually involves moderate activity. When not at work,
she spends eight hours in bed, 4-6 hours in sitting and moving about, and two hours in
walking, active recreation or household duties”.
Energy
An adequate, healthy diet must satisfy human needs for energy and all essential nutrients.
Furthermore, dietary energy needs and recommendations cannot be considered in isolation
of other nutrients in the diet, as the lack of one will influence the others. The energy
requirement of an individual has been defined as “the level of energy intake from food that
will balance energy expenditure when the individual has body size and composition and
57
level of physical activity, consistent with long term good health and that will allow for
maintenance of economically necessary and socially desirable activity”.
Energy expenditure is the amount of energy (or calories) that a person needs to carry out a
physical function such as breathing, circulating blood, digesting food, or physical
movement.
The components of energy expenditure include:
▪ Basal Metabolic Rate (BMR)- Basal metabolic rate is the energy burned when an
organism is inactive. It is the energy expended when an individual is lying and resting
after sleep.
▪ Thermic Effect of Food- It is the energy required to process the food we eat.
Approximately 10% of the calories in a meal are used to digest, metabolize, and store
the food just eaten. The energy expenditure is directly related to the size of the meal
and the food composition (i.e., the amount of protein, fat, and carbohydrate).
▪ Nature and duration of activity- The allowances for those engaged in heavy work
should be higher than those doing either sedentary or moderate work.
Sedentary or light activity lifestyles
A sedentary lifestyle is a type of lifestyle involving little or no physical activity. A
person living a sedentary lifestyle is often sitting or lying down while engaged in
an activity like reading, socializing, watching television, playing video games, or
using a mobile phone/computer for much of the day, for example Office workers,
professional like lawyers, doctors, accountants, teachers and architects, housewives
using mechanical appliances or servants, teachers and most other professionals.
Moderate activity lifestyles
Moderate intensity activities are defined as activities require more oxygen
consumption that light activities. These people have occupations that are not strenuous
in terms of energy demands but involve more energy expenditure than that described
for sedentary lifestyles. For example, construction works (excluding heavy labour),
many farm workers, housewives without mechanical household appliances or
servants, departmental store workers.
Heavy activity lifestyles
Vigorous intensity activities are defined as activities that require the highest amount
of oxygen consumption to complete the activity. These people engage regularly in
strenuous work or in strenuous leisure activities for several hours. Examples of
vigorous physical activities include agricultural workers, labourers, soldiers or active
service, mine and steel workers, athletes.
The categories shown in Table 5.1 represent the different levels of activity associated
with a population’s lifestyle.
58
Table 5.1: Classification of lifestyles in relation to the intensity of habitual
physical activity, or PAL
Category PAL value
Sedentary or light activity lifestyle 1.40-1.69
Active or moderately active lifestyle 1.70-1.99
Vigorous or vigorously active lifestyle 2.00-2.40*
* PAL values > 2.40 are difficult to maintain over a long period of time
The Physical Activity Level (PAL) is a way to express a person's daily physical
activity as a number and is used to estimate a person's total energy expenditure.
In addition to physical activity and the type and nature of non-occupational
activities, the energy requirements of individuals also depend on factors such as body size
and composition, age, sex and climate. Energy expenditure depending on body size and
composition will be influenced by resting metabolism, the physical effort of moving the
whole body, the work of standing and maintenance of posture, and small movements of the
limbs. Also, the total physical activity of an individual may be influenced by the quantity
of adipose tissue in the body. The energy requirement of women is less than that of men,
because they have a larger proportion of fat. The energy expenditure of adults may change
with age because of changes in body weight or body composition (as in old age). It is
generally recognized that the energy requirements of people in cold climates is more than
that of those in hot climates.
Protein: It is required by a normal adult for maintaining the tissue integrity and repairing
and replacing the protein loss by wear and tear. An allowance of 1g/kg body weight has
been recommended. Thus, the total daily allowance of protein of an average Indian man
weighing 60 kg will be 60 g and for an average Indian woman weighing 55 kg will be 55
g.
Fat: The two factors that need to be considered while assessing fat requirements are
o The invisible fat in the diet which supplies majority of the essential fatty acid
requirements.
o A certain amount of visible fat is required to meet requirements of two essential
fatty acids i.e., linoleic and linolenic fatty acids.
59
The requirement of linoleic acid has been estimated to be 3 percent of total energy
requirement, which can be met by 12 g of visible fat. To provide energy density and
palatability to the diet the ICMR has suggested 20 g visible fat per day. The type of visible
fat used is also important. Oils containing high amount of saturated fatty acids may increase
the linoleic acid requirements and are detrimental to health. Hence combination of oils with
equal proportion of saturated, monounsaturated and polyunsaturated fatty acids has been
recommended.
Minerals
Iron
The loss of iron through sweat, gastrointestinal tract and urine is estimated to be 14 g/kg
body weight. The iron requirement is 21 mg for women and 17 mg for men. The women
normally lose upto 2mg of iron per day in the menstrual blood and thus iron
deficiency anaemia is more common among women.
Calcium and Phosphorus
In adults calcium is required for replacing calcium lost from body through urine, faeces,
sweat and bile. Of the dietary calcium only 20 to30 percent is absorbed and this is facilitated
by vitamin D.ICMR has suggested recommended allowance of calcium for men and
women is 600 mg. Along with this, a desirable intake of phosphorus is recommended as
the functions of calcium and phosphorus is closely linked. The elemental Ca:P ratio in the
diet should be maintained at 1:1.
Vitamins
Vitamin A
The ICMR has suggested 600 μg of retinol for both men and women equivalent to 4800 μg
of β carotene. Since Indian diets contain both retinol and β carotene it is advisable to
express the Vitamin A content of diet in terms of retinol equivalents.
Retinol equivalent = μg of retinol + 1/8 mg of β-carotene.
Vitamin C (Ascorbic acid)
The concentration of Vitamin C in circulating leukocytes reflects the tissue concentration.
Based on this a daily intake of 20 mg vitamin C is sufficient to maintain satisfactory
ascorbic acid status. Considering 50 percent loss of vitamin C during cooking ICMR has
recommended RDA of 40 mg vitamin C per day for both men and women.
B Complex vitamins
Recommended allowances of folic acid and Vitamin B12 are same for normal adult men
and women 200 μg of folic acid and 1 μg of vitamin B12. Thiamine, Riboflavin and Niacin
requirements vary according to the energy requirements. For men, Thiamine requirement
varies from 1.2 to 1.7 mg/day for women 1.0 to 1.4 mg/day. Riboflavin for men varies from
1.4 to 2.1 mg/day and for women 1.1 to 1.7 mg/day.
60
Table 5.2: RDA for Adult Men and Women
Nutrient Men (Body Weight 60 kg) Women (Body Weight 55 kg)
Sedentary Moderate Heavy Sedentary Moderate Heavy
Energy (kcal/d) 2320 2730 3490 1900 2230 2850
Protein (g/d) 60 60 60 55 55 55
Visible fat (g/d) 25 30 40 20 25 30
Calcium (g/d) 600 600 600 600 600 600
Iron (mg/d) 17 17 17 21 21 21
Zinc (mg/d) 12 12 12 10 10 10
Vitamin A
(μg/d)
Retinol 600 600 600 600 600 600
β-carotene 4800 4800 4800 4800 4800 4800
Thiamine
(mg/d)
1.2 1.4 1.7 1.0 1.1 1.4
Riboflavin
(mg/d)
1.4 1.6 2.1 1.1 1.3 1.7
Niacin
equivalent
(mg/d)
13 18 21 12 14 16
Vitamin B6
(mg/d)
2.0 2.0 2.0 2.0 2.0 2.0
Ascorbic acid
(mg/d)
40 40 40 40 40 40
Dietary folate
(μg/d)
200 200 200 200 200 200
Vitamin B12
(μg/d)
1.0 1.0 1.0 1.0 1.0 1.0
Source: ICMR (2010)
61
DIETARY CONSIDERATIONS
• The diet should be nutritionally balanced. Emphasis should be that each meal is
nutritionally balanced. The day’s nutritional needs of the individual should be
divided almost equally in the three main meals i.e. breakfast, lunch and dinner.
• In case of persons going to office a nutritious, well balanced, attractive and easy to
carry packed lunch must be provided.
• Careful attention needs to be given to the amount and type of fat to be included in
the diet so as to reduce risk of hypertension (high blood pressure) and heart
diseases.
• Traditions, customs and religious attitude of the person should be considered.
• Likes and dislikes should be taken into consideration. If, however, a particular
group is not liked, then it may be given in some other form e.g. instead of milk,
curd, paneer, custard etc. may be given.
• Variety in the food is a must, if should be provided in terms of colour, texture
and flavour.
• The diet should be planned according to the socio-economic status the person.
Selection of the food stuffs should be such that they are purchased within the
budget. If expensive foods cannot be afforded then emphasis should be on cheap,
yet, nutritious food stuffs e.g. peanuts, green leafy vegetables etc.
• Availability of time and energy of the person should be considered. If the plan is
for a working woman, then elaborate cooking can be avoided.
• The planned menu should be according to the season. Seasonal vegetables and fruits
should be selected as they are tastier, nutritious, cheaper and easily available.
Seasonal drinks may be included to make the plan interesting.
• The diet should be planned such that it provides us sufficient satiety value.
Adequate amounts of raw fruits and vegetables should be included to provide
sufficient dietary fiber.
• Meals should be served in a pleasant atmosphere.
SAMPLE DIET PLAN
A day’s sample menu for a woman (Business executive) doing light work
Recommended Dietary Allowances
Activity: Sedentary
Energy -- 1900 Kcal Protein -- 55 g Iron -- 21 mg
62
Meal Menu Food Stuffs Amount (g)
Bed Tea Tea Milk
Sugar
25
5
Breakfast
Coffee Milk
Sugar
120
5
Stuffed Omelette Egg
Onion
Mushroom
Oil
40
40
25
10
Toasted Bread Bread
Butter
50
10
Lunch
Stuffed Paranthas Wheat Flour
Methi
Oil
75
25
10
Dry Peas & Paneer
or Minced Meat Paneer/meat
Peas
Onion
Tomato
Fat
50
30
25
25
5
Coffee (from office) Milk
Sugar
50
5
Tea
Orange
Tea Orange
Milk
Sugar
80
25
5
Tomato and
Cheese Sandwiches Bread
Cheese
Tomato
Butter
50
20
50
10
Dinner
Dal Soup Arhar Dal
Onion
Potato
Butter
30
30
30
6
Pulao Rice
Beans
Peas
Carrot
Potato
70
30
30
20
30
30
5
63
Onion
Fat
Bathua Raita Curd
Bathua
75
50
Salad Cucumber
Capsicum
Tomato
30
30
30
Barfi Khoa
Sugar
25
5
A day’s diet for a woman labourer doing heavy work
Recommended dietary Allowance
Activity : Heavy
Energy -- 2850 Kcal Protein -- 55 g Iron -- 21 mg
Meal Menu Food Stuffs Amount (g)
Breakfast Tea Milk
Sugar
25
10
Besan Roti Atta 160
Besan 40
Onion 30
Coriander Chutney Coriander 50
Lunch Chapati Wheat Flour 200
Fat 10
Spinach and Potato
Vegetable Spinach
Potato
Fat
100
100
5
Salad Onion
Tomato
50
20
Jaggery
Banana Jaggery
Banana
40
100
Tea Tea Milk
Sugar
25
10
Rusk Rusk 30
Guava Guava 80
Dinner Rice
Chana Dal with Vegetable
Radish-leaves bhuji
Rice
Chana Dal
Bottle Gourd
200
40
100
100
64
Radish-leaves
Radish
Fat
100
5
Onion
Jaggery Onion
Jaggery
50
40
NUTRITIONAL CONCERNS
The major nutritional problems encountered in both developing and developed countries
are excess macronutrient intake (especially saturated fat, protein, and sugar) and
insufficient intake of the fibre and micronutrients provided by vegetables, fruits, grains,
and legumes.
▪ Undernutrition
Under nutrition describes a condition whereby normal nutritional guidelines and
recommendations are not met. It can result from inadequate food intake, poor
absorption of nutrients or excessive loss of nutrients. This usually results in loss of
body weight.
▪ Anaemia
Anaemia in India is a problem of major public health significance. It is defined as a
reduction in haemoglobin concentration, red-cell count, or packed-cell volume
below established cut-off levels. Women in the reproductive age group are the most
affected. The causes of anaemia may be
o Inadequate diet in quality and quantity, deficient in folate, Iron, B complex
vitamins and vitamin C.
o Excessive menstruation
o Poverty
o Lack of awareness
o Poor environmental hygiene and sanitation
▪ Iodine deficiency disorders
Iodine is an essential component of thyroxine (T4) and triiodothyronine (T3), and
it must be provided in the diet. Inadequate iodine intake leads to inadequate thyroid
hormone production, and all the consequences of iodine deficiency stem from the
associated hypothyroidism.
65
▪ Lifestyle related disorders
o Obesity- Obesity is defined as an “abnormal or excessive fat accumulation that
presents a risk to health”. For adults, overweight and obesity ranges are
determined by using weight and height to calculate the “Body Mass Index”. It
is defined as body weight in kilograms divided by the square of the height in
meters (kg/m2). It is also called as Quetelets Index.
The WHO defines a BMI equal to or greater than 25 as an overweight category
and a BMI equal to or greater than 30 as obesity. International Obesity Task
Force (IOTF) has also given the classification of obesity in Asia in 2000 (Table
5.3) which is different from that of WHO, due to the increased fat percentage
in Asians as compared to Caucasians for the same weight.
Table 5.3 Classification of weight status according to Body Mass Index
(BMI)
o Metabolic syndrome-The metabolic syndrome is a constellation of interrelated
risk factors of metabolic origin—metabolic risk factors (dyslipidemia, elevated
blood pressure, and elevated plasma glucose) and underlying risk factors
(abdominal obesity, insulin resistance, physical inactivity), which give rise to the
metabolic risk factors.
o Hypertension- High blood pressure, or hypertension, occurs when your blood
pressure increases to unhealthy levels. It can lead to heart disease, stroke, and death
and is a major global health concern.
o Cardiovascular disease- Those in the high socioeconomic group who adapt a
sedentary lifestyle and have a high intake of saturated fatty acids tend to develop
cardiovascular disease. The incidence is high in obese individuals.
o Diabetes- Type II diabetes is more prevalent among adults. Obese individuals are
identified to be at risk. Malnutrition related diabetes occurs in young people
between 15 to 30 years of age who are lean and undernourished. Acute stress is
another common cause of diabetes among working women and executives.
66
LET’S CHECK THE PROGRESS
1. What are the various factors influencing energy requirement of adults?
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
2. List the factors you would keep in mind while planning diets for adults.
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
3. Briefly explain the following:
• Reference Indian Man
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
• Reference Indian Woman
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
SUMMARY
As growth ceases during adulthood, nutrients are required primarily for the maintenance of
health and to prevent diseases. The energy requirement of adults depends on BMR and the
physical activity level. A balanced diet rich in fruits and vegetables; limited in fat, salt and
sugar; regular exercise is all helpful in promotion physical and mental health.
KEY WORDS
Body Mass Index (BMI)- body weight in kilograms divided by height in square meters.
RDA- Recommended Dietary Allowance- it is the average daily intake of nutrient sufficient
to meet the nutrient requirement of nearly all (97-98%) individuals of a given population.
REFERENCES
➢ Chadha, R., & Mathur, P. (2015). Nutrition: A Lifecycle Approach. 1st Ed. Orient
Black Swan.
67
➢ ICMR. Nutrient requirements and recommended dietary allowances for Indians. A
report of the expert group of the Indian Council of Medical Research, National
Institute of Nutrition, Hyderabad. 2010.
➢ NIN. Dietary Guidelines for Indians- A Manual. Indian Council of Medical Research,
National Institute of Nutrition, Hyderabad, 2011.
➢ Normal and Therapeutic Nutrition; Robinson and Lawler; 16th Edition.
➢ Applied Nutrition; Third Edition, R. Rajalakshmi.
➢ Food and Nutrition, Students Edition, Dr. M. Swaminathan.
➢ Essentials of Foods and Nutrition; S.R. Mudambi, M.V. Rajagopal.
68
LESSON 6
NUTRITION DURING PREGNANCY
INTRODUCTION
Pregnancy is that state in a woman’s life, when there is the growth and development of
foetus in her body. She has the responsibility of supporting the growth of foetus internally
during nine months of pregnancy due to which the adult women’s need are increased. It is
the desire of every mother to give birth to a healthy baby, therefore good nutrition is a must
for the expectant mother.
OBJECTIVES
After going through this lesson, you will be able to
❖ Understand the nutritional implications of the phase of pregnancy.
❖ Describe the physiological changes during pregnancy.
❖ Plan balanced diet for pregnant woman by taking into consideration various factors.
PREGNANCY
Pregnancy is a period of great physiological as well as psychological stress for
women. During pregnancy, the mother has to meet her own needs and the needs of the
growing foetus. There is additional need for the growth of the other related tissues; and to
build up fat stores to cushion the foetus, prior to birth, and to supply part of the energy
needed for milk formation during lactation. Thus, the need for additional nutrients involved
in tissue synthesis is increased during pregnancy for the fast-growing foetus.
Since earliest times, the diet of pregnant women has been considered to be of great
importance. It was believed that the foods eaten by the pregnant women had an influence
on the physical characteristics and behaviour of the unborn child. Consequently, certain
rigid rules as to what foods a pregnant woman should and should not eat were laid down
by various societies. Even today, several superstitions on this subject prevail among many
people in our country.
In the first trimester of pregnancy, the rate of growth of the foetus is very slow and
the mother is not able to take much food because of nausea and vomiting, which are very
common during this period. It is during the next two trimesters that the foetus grows rapidly
and therefore, the nutritional needs are increased. Adolescent mothers, who have not
completed their own growth, may be affected, which may indirectly affect the welfare of
the foetus. If the mother’s diet has been adequate before pregnancy, she may be in a better
position to meet the demands of pregnancy.
69
No mother would like to injure the health of her baby through poor food habits.
However, nutritional studies have shown that many women attend to the needs of other
family members at the expense of their own needs. This situation does not change during
pregnancy. Thus, pregnant women are often most poorly fed members of the family. In her
effort to take care of the others, she does not take time to sit down and eat. When she is
very tired, she is unable to eat. If the food supply is limited (in low income group families),
she is the worst affected, as she feeds all other members and eats what is left. It is important
that the family should plan the arrival of the baby so that the pregnant mother does not
suffer from lack of food both in terms of amount and kind. The expectant father must try
to ensure that the expectant mother gets the right amount and kind of foods, so that the
health of the foetus does not suffer.
PHYSIOLOGICAL CHANGES IN PREGNANCY
Women’s bodies change during pregnancy to ensure that their unborn children get
enough food and other things that they need. These changes already start happening in early
pregnancy and become more and more noticeable as time goes on. The changes that a
woman’s body undergoes are anatomical, physiological and biochemical changes. These
bodily changes help the expectant mother in adapting the increasing demands during this
vulnerable phase. Therefore, it is important to understand these changes.
• Cardiac changes- Changes in the cardiovascular system in pregnancy begin early in
pregnancy where the cardiac output is increased by 20%. The maximum cardiac output
is found at about 20–28 weeks’ gestation.
• Alimentary system changes- The functions of gastrointestinal system changes in
several ways that affect nutritional status. Nausea and vomiting are very common
complaints in pregnancy. This might be an adaptive mechanism of pregnancy, aiming
at preventing pregnant women from consuming potentially teratogenic substances such
as strong-tasting fruits and vegetables. It has been observed that the pregnant women
often show craving for some foods and aversion to others. In later trimester of
pregnancy absorption of nutrients like vitamin B12, iron and calcium increase in order
to meet the increased needs of the mother and foetus. As pregnancy progresses,
mechanical changes in the alimentary tract also occur, caused by the growing uterus.
The stomach is increasingly displaced upwards
• Renal system changes- Due to foetal and maternal metabolism during pregnancy, there
is an increased production of various metabolites like creatinine, urea and other waste
products. To facilitate their clearance, the rate of blood flow through the kidneys is
increased with a subsequent increase in the rate of glomerular filtration in the nephrons.
The rate of excretions of water is very high in mid-pregnancy and very low in advanced
pregnancy.
70
• Haematological changes- Plasma volume increases progressively throughout normal
pregnancy. Most of this 50% increase occurs by 34 weeks’ gestation and is proportional
to the birth weight of the baby. Because the expansion in plasma volume is greater than
the increase in red blood cell mass (about 20 per cent), there is a fall in haemoglobin
concentration, haematocrit and red blood cell count.
• Respiratory changes- There is a significant increase in oxygen demand during normal
pregnancy. This is due to a 15% increase in the metabolic rate and a 20% increased
consumption of oxygen.
• Metabolic Changes- Maternal metabolism changes substantially during pregnancy.
Basal metabolic rate- Due to foetal growth and development there is an increase in
basal metabolic rate which rises by about 5% in the 1st trimester reaching to as high a
level as 12% during later stages of pregnancy, when the rate of foetal growth is very
high.
Carbohydrate and fat metabolism-Early gestation can be viewed as an anabolic state in
the mother with an increase in maternal fat stores and small increases in insulin
sensitivity. Hence, nutrients are stored in early pregnancy to meet the foeto-placental
and maternal demands of late gestation and lactation. In contrast, late pregnancy is
better characterized as a catabolic state with decreased insulin sensitivity (increased
insulin resistance). An increase in insulin resistance results in increases in maternal
glucose and free fatty acid concentrations, allowing for greater substrate availability for
foetal growth.
Water- Pregnancy is characterized by increases in the amount of body water and in the
total volume of body fluid. During pregnancy between 3,500 and 4,000 millilitres of
fluid will be added to that already present in the tissues of a healthy woman. The uterus,
the placenta, the amniotic fluid, and the foetus each account for approximately equal
amounts. In addition to the water that increases blood volume, there is also added fluid
in the mother’s muscles, her pelvic soft tissues, her breasts, and her other tissues.
Toward the end of pregnancy, a considerable amount of retained fluid accumulates in
the woman’s lower extremities. It is this fluid that produces the pitting and swelling of
the legs that many normally pregnant women display.
Minerals-The pregnant woman’s reserves and intake of iron and calcium must be
enough not only for her own needs but also for those of the foetus. An increase in serum
copper levels occurs during pregnancy. The mother has some phosphorus reserve but
must acquire enough from her diet to supply her own tissues and those of the foetus.
• Hormonal changes-During pregnancy there is increased secretion of the following
hormones:
o Aldosterone by the adrenal gland.
71
o Progesterone which relaxes uterine muscles to expand to accommodate the
growing foetus.
o Thyroxin.
o Parathormone.
WEIGHT GAIN IN PREGNANCY
Gestational weight gain (GWG) is a unique and complex biological phenomenon that
supports the functions of growth and development of the foetus. Gestational weight gain is
influenced not only by changes in maternal physiology and metabolism, but also by
placental metabolism (Figure 6.1).
Figure 6.1: Schematic summary of components of gestational weight gain
The total amount of weight gained in normal-term pregnancies varies (Figure 6.2)
considerably among women. Women are likely to gain more weight in the final months of
pregnancy than they do in the first few months. This isn't only due to the weight of the
growing baby. Much of the weight gained is extra fluid (water) in the body. This is needed
for things like the baby’s circulation, the placenta and the amniotic fluid. Gain in weight
varies widely, being somewhat greater in young women, than those who are older, and
greater in those who are having their first babies.
Figure 6.2: Components of gestational weight gain
Source: Pitkin, 1976.
72
There is no standard recommended amount of weight gain that applies to every
pregnant woman. The recommendations are now based on women’s pre-pregnancy weight.
Petite, underweight women should put on more weight than women who were overweight
before they became pregnant.
The U.S. Institute of Medicine (IOM), 2009 issues guidelines that are followed by
doctors around the world. Their recommendations about BMI and weight gain in pregnancy
are as follows:
o For women who are underweight before pregnancy (BMI of less than 18.5)- between
12.5 and 18 kilograms of weight gain during pregnancy.
o For women who are of normal weight before pregnancy (BMI of between 18.5 and
24.9)-between 11.5 and 16 kilograms of weight gain during pregnancy.
o For women who are overweight before pregnancy (BMI of between 25 and 29.9)-
between 7 and 11.5 kilograms of weight gain during pregnancy.
o For women who are obese before pregnancy (BMI greater than 30)- between 5 and 9
kilograms of weight gain during pregnancy.
COMMON COMPLICATIONS DURING PREGNANCY
▪ Nausea and vomiting- During the first trimester, the physiological and bio-chemical
balances are often disturbed, possibly because of excessive hormone production.
Gastro-intestinal upsets, including loss of appetite, nausea and vomiting are relatively
frequent, loss of weight occasionally takes place because of inability to take sufficient
food. Mild early morning nausea may usually be overcome by the use of high
carbohydrate foods, such as rusk dry toast, hard candy, parched grains, eaten before
rising may be of help. Small frequent, meals rather than large ones are preferable. Fluids
should be taken between meals, rather than at meal time. Fatty foods, such as fried
foods, deserts, sweets, excessive seasoning, coffee and strongly flavoured vegetables
may be restricted or eliminated if nausea persists.
▪ Constipation- The occurrence of constipation, especially during the latter half of
pregnancy is common. The contributing factors may be the amount of pressure exerted
by the developing foetus on the digestive tract, the limitation of exercise and
insufficient bulk. Restrictions of physical activity is not advisable as exercise not only
helps elimination, but also keeps the body fit.
▪ Heart Burn/ Gastric Pressure- Sometimes pregnant women complain about a ‘feeling
of fullness’ or ‘heart burn’. Such complaints or discomforts are generally felt after
meals. These are usually due to pressure of the enlarging uterus crowding the stomach,
therefore causing difficulty in after eating. Food mixtures may sometimes be pushed
back to the lower oesophagus, causing a burning sensation due to gastric acid mixed
73
with the food mass. Evidently, this complaint has nothing to do with the heart itself.
This feeling is only due to closeness of lower oesophagus to the heart. The feeling can
be avoided by taking small frequent meals.
▪ Toxaemia- The term toxaemia means a combination of symptoms including
hypertension, oedema and albuminuria. Preeclampsia is the appearance of
hypertension, oedema of the face and hands, and/or albuminuria about the twentieth
week of pregnancy. It should be suspected when there is a sudden gain in weight,
including fluid retention, rather than tissue building. Eclampsia is the end result of
preeclampsia and it includes earlier symptoms, but may culminate in convulsions.
Protein and calorie restriction are no longer recommended, and sodium restriction
should be used with caution.
▪ Anaemia- A pregnant woman is labelled anaemic if the blood haemoglobin is less than
10g/100ml from the 28th week onwards. A significant fall in birth weight due to
increase in prematurity rate and intrauterine growth retardation can occur if the
haemoglobin level goes below 8 g / 100 ml.
▪ PICA and ptyalism-
Pica is a strange food cravings of eating non-food materials, such as dirt, clay, and
flaking paint that occur during pregnancy. In some cases, a lack of certain nutrients,
such as iron and zinc, may trigger these unusual cravings.
Ptyalism gravidarum or hyper salivation is derived from the Greek ‘ptyalizien’,
meaning “to spit much” and is usually defined as an excessive secretion of saliva.
▪ Pregnancy induced hypertension (PIH)-PIH is a major pregnancy complication
associated with premature delivery, intra-uterine growth retardation (IUGR), abruptio
placentae, and intra-uterine death, as well as maternal morbidity and mortality.
There exist several hypertensive states of pregnancy:
o Gestational hypertension-Gestational hypertension is usually defined as
having a blood pressure higher than 140/90 measured on two separate
occasions, more than 6 hours apart, without the presence of protein in the urine
and diagnosed after 20 weeks of gestation.
o Pre-eclampsia- Preeclampsia is a pregnancy-specific, multisystem disorder
that is characterized by the development of gestational hypertension and
proteinuria after 20 weeks of gestation.
o Eclampsia-This is when tonic-clonic seizures appear in a pregnant woman
with high blood pressure and proteinuria.
74
Miscellaneous factors
▪ Alcohol- The habitual use of alcohol during pregnancy can cause foetal damage.
Extensive or habitual alcohol use may produce offspring with foetal alcohol syndrome
(FAS). Infants with FAS are premature and have low birth weight.
▪ Caffeine can cross the placenta and enter foetal circulation. Pregnant women who are
heavy coffee drinkers are considered at risk for miscarriages, premature deliveries and
may give birth to small for date infants.
▪ Drugs- Drug use pregnancy-medical or recreational- also leads to numerous problems.
Recreational drugs like heroin, LSD, marijuana lead to poor prenatal weight, short or
prolonged labour and other prenatal problems.
▪ Smoking during pregnancy results in placental abnormalities and foetal damage
including prematurity and low birth weight. This is mainly due to reduced blood flow,
which affects the oxygen and nutrient transport through the placenta.
IMPORTANCE OF GOOD NUTRITION DURING PREGNANCY
A well-nourished woman prior to conception enters pregnancy with reserve of several
nutrients that meets the needs of the growing foetus without affecting her own health. A
well-nourished woman suffers fewer complications during pregnancy & there are few
chances of premature births and will give birth to a healthy child. Maternal diet during
pregnancy has a direct influence on foetal growth, size & health of the new-born. Poor
nutrition during pregnancy increases the risk of complications such as prolonged labour
and even death. Inadequate diet during pregnancy affects the health of the baby during
early infancy. If the infants survive they develop nutritional diseases like anaemia, rickets
etc. or suffer from infectious diseases due to lack of good immunity.
Malnutrition and foetus-Chronic moderate malnutrition and anaemia during pregnancy
may result in still birth and Low Birth Weight (LBW) babies weighing less than 2500g. A
large number of such babies are premature (<37 weeks of gestation) and rest suffer from
Intra Uterine Growth Retardation (IUGR). IUGR results in babies which are Small For
Date (SFD) i.e., infants born after 40 weeks of gestation but small because of malnutrition
during intrauterine growth. The risk of Low Birth Weight babies and the related neonatal
mortality is associated with one or more of the following factors.
o Low socioeconomic status.
o Poor maternal nutritional status.
o Small stature of the mother.
o Low pre-pregnancy weight for height.
o Biological immaturity (mothers less than 17 years).
75
o Low weight gain during pregnancy.
o Smoking, consumption of alcohol, use of drugs.
o Infectious diseases.
o Lack of education, poor knowledge on sound nutrition.
o Lack of motivation towards wanted pregnancy.
Effect of malnutrition on placenta- The placenta of malnourished mothers have fewer
cells than well-nourished mothers. The reduction in the number of cells reduces the ability
of the placenta to
o synthesize substances required by the foetus
o transfer nutrients
o inhibit the passage of potentially harmful substances to the growing foetus
Effect of malnutrition on maternal health- A malnourished mother supplies nutrients to
the foetus at the expense of her own tissues. Multiple micronutrient deficiencies during
pregnancy like vitamin A, zinc, iron and folic acid are common and are associated with
complications during pregnancy and labour. This may lead to abortion and even death of
the mother.
Effect of malnutrition during infancy- Inadequate nutrition during foetal life affects the
health of the baby during infancy. Such infants develop nutritional deficiency diseases like
rickets, anaemia or suffer from infectious diseases due to low resistance. Hence it is
essential to meet the increased nutritional needs of a pregnant mother.
NUTRITIONAL REQUIREMENTS DURING PREGNANCY
Energy-The energy cost of pregnancy is determined by the energy needed for maternal
gestational weight gain, which is associated with protein and fat accretion in maternal,
foetal and placental tissues, and by the increase in energy expenditure associated with basal
metabolism and physical activity.
o Protein and fat deposition during pregnancy
o Basal metabolism in pregnancy
o Total energy expenditure during pregnancy
The Indian Council of Medical Research (2010) recommends an increase of 350 KCal
per day (Table 6.1) during the second and third trimester of pregnancy. This takes into
consideration additional energy needed to support the growth of the foetus, placenta and
maternal tissues, as well as to meet the increased metabolic rate. BMR increases by about
5% during the first and second trimester and about 12% during the third trimester. As
growth of the foetus is very rapid during this period, it is important that the increased need
76
for energy is met. Enough energy containing food should be supplied to ensure that the
dietary protein is used for building new tissues, and not to meet energy requirements.
During first trimester of pregnancy, the demand for extra energy is small and is taken care
of by the reduced activity.
Table 6.1: Recommended Dietary Allowance (RDA) for energy, protein, fat and
minerals for pregnant woman
Nutrients Sedentary Activity Moderate Activity Heavy Activity
Energy (kcal/d) 1900
+350
2230
+350
2850
+350
Protein (g/d) 78
Visible fat (g/d) 20 25 30
Calcium (g/d) 1200
Iron (mg/d) 35
Source: ICMR (2010)
Protein- Additional protein is necessary for growth of the foetus, new maternal tissues and
to prepare the mother for lactation. The ICMR recommends additional 23g per day during
the second half of pregnancy. The protein should be of good quality. The pulse: cereal ratio
should be at least 1:5 in a pregnant women diet.
Fats and Essential Fatty Acids (EFA)-ICMR Expert Committee has suggested an intake
of 30g of visible fat/day during pregnancy to meet essential fatty acid requirement. This
level of fat intake would also provide necessary energy density to the diet. The calories
provided by the total amount of fat (visible and invisible) should be 20-30 per cent of the
total energy.
Calcium-During pregnancy additional calcium is needed for growth and development of
bones as well as teeth of the foetus. ICMR (2010) has therefore, recommended a total of
1200mg of calcium which takes care of the total calcium needs of the mother and the
additional needs of pregnancy. If these requirements are not fulfilled, then the mother’s
bones is mobilized resulting in demineralization of maternal bones leading to easy
fractures.
Zinc-Zinc has an important role to play in pregnancy. Apart from being a component of
several enzyme systems it participates in the synthesis of nucleic acids – DNA and RNA
highlighting its significance in the process of reproduction. Maternal zinc deficiency may
compromise infant development and lead to poor birth outcomes. Low plasma zinc
concentrations reduce placental zinc transport and may affect the supply of zinc to the
foetus.
Iron-Iron is needed for the additional volume of blood and other tissues formed during
development of foetus. The store for iron is built during prenatal period, because milk, the
infant’s main food during first three to four months is deficient in iron. It is now a common
77
practice for the doctor to give expectant mothers a prescription for an iron supplement.
Though this is true, foods rich in iron should be emphasized in the diet. The iron intake
during this period is recommended at 35 mg per day, considering an 8% absorption.
Iodine- There is an additional need for iodine at this stage in life. If mother’s iodine intake
is low, the infant may suffer from cretinism, a disease characterized by retarded physical
and mental development. Due to increase in BMR, iodine requirement are enhanced. The
recommendation for iodine is 250 mcg/ day.
Vitamins-Additional intake of 200mcg of vitamin A has been recommended during this
period. No additional intake has been recommended for vitamin D, in the absence of any
experimental data. However, the requirement for vitamin D may be higher during pregnancy,
when calcium metabolism is under physiological stress. Since vitamin C allowances for
adults includes a sufficiently safe margin, the requirements being small, only 20 mg extra
allowance has been recommended. The additional intake of thiamine, riboflavin and niacin
has been recommended is 0.2 mg, 0.3 mg, and 2.0 mg, per 1000 kcal respectively, correlating
with the increased calorie intake. Increased energy allowance will provide the increased B
complex vitamins. An increased level of vitamin B6 (pyridoxine) at 2.5 mg/day is
recommended. Folic acid intake is increased to 500 mcg/day. It is difficult to provide this
amount through food and the additional needs may have to be met through supplements of
medicinal folate. Information regarding additional needs of vitamin B12 (cobalamin) during
pregnancy is limited. However, on the basis of various studies, ICMR has suggested a daily
intake of 1.2 mcg vitamin B12 during pregnancy. It, therefore, is clear that the nutritional
needs during pregnancy are increased.
Table 6.2: Recommended Dietary Allowance (RDA) for vitamins for pregnant woman
Nutrient Sedentary Activity Moderate Activity Heavy Activity
Vitamin A (μg/d)
Retinol 800
β-carotene 6400
Thiamine (mg/d) 1.0 + 0.2 1.1 + 0.2 1.4 + 0.2
Riboflavin (mg/d) 1.1 + 0.3 1.3 + 0.3 1.7 + 0.3
Niacin (mg/d) 12 + 2 14 + 2 16 + 2
Vitamin B6 (mg/d) 2.5
Ascorbic acid (mg/d) 60
Dietary folate (μg/d) 500
Vitamin B12 (μg/d) 1.2
Source: ICMR (2010)
78
DIETARY CONSIDERATIONS
Guidelines for eating during pregnancy
• It is important that the expectant mother gets the right amount and kind of food, so
that the health of foetus does not suffer as nutrition requirements increases
tremendously.
• During pregnancy as she not only has to nourish herself but also growing foetus.
• Enough energy food should be supplied to ensure that the dietary protein is used for
building new tissues and not utilized to meet the energy requirements. Protein of good
quality e.g. milk, egg, fish, meat need to be used.
• Good quality protein may be achieved by a combination of vegetable proteins and
milk. Intake of vitamins and minerals should be sufficient by including liberal amounts
of leafy vegetables, other vegetables and fruits.
• During the period of nausea and vomiting, some plan be made to include carbohydrate
foods available during early morning.
• Since the pregnant woman is not able to eat much at a time, meals must be planned
with smaller intervals i.e. 4-5 small meals. Some women may prefer three large meals.
• The meals must also be placed to provide for drinks such as buttermilk, milk, or lemon
juice and simple snacks between meals. Taking lemon juice or orange juice in the
morning and before meals helps to relieve the nausea of pregnancy.
• To meet the additional iron need, foodstuffs like whole grain cereals, whole pulses,
some leafy vegetables like mustard leaves, bathua etc., dried fruits, eggs, organ meats
should be included in the diet.
• The liking and tolerance of the pregnant woman should be kept in mind, especially in
the early part of pregnancy.
• Rich, sweet, fried and other fatty foods should be avoided. These are more harmful
than helpful.
• The restriction of salt may be necessary, consumption of pickles, chutneys, etc. rich in
salt must be avoided.
• Emphasis should be on eating more of the same food.
• Variety in terms of colour, texture and flavour is necessary, especially if the expectant
mother does not feel hungry.
• During pregnancy due to foetal pressure, constipation is common. Therefore, longer
quantities of foods rich in dietary fibre in fresh fruits and vegetables, whole grain
cereals, husked pulses with plenty of fluids need to be included in the diet.
79
• Socio-economic status of the expected mother should be kept in mind and cheap, yet
nutritious food items may be selected for a woman belonging to low socio-economic
status. e.g. groundnuts, jaggery and leafy vegetables for cheap iron sources.
• Meals should be served in a pleasant atmosphere
SAMPLE DIET PLAN
A Day’s diet plan for a pregnant woman of 27 years in third trimester from middle income
group and doing Moderate work
Recommended dietary Allowance (RDA) as per ICMR 2010
Energy -- 2580 Kcal Calcium -- 1200mg
Protein -- 78g Iron -- 35mg
Menu plan
MEAL MENU FOOD STUFFS AMOUNT (G)
Early morning Tea Milk
Sugar
50
5
Rusk Rusk 60
Breakfast Milk Milk
Sugar
150
5
Toasted Bread Bread
Butter
60
10
Boiled Egg Egg 50
Mid-morning Orange Juice Orange Juice 200
Salty Biscuits Salty Biscuits 20
Lunch Chapati Wheat flour 90
Fat 10
Arhar Dal Arhar
Tomato
Fat
30
25
5
Methi & Potato
Vegetable Methi
Potato
Onion
100
75
25
5
80
Fat
Sweet Raita Curd
Apple
Banana
Sugar
75
25
25
5
Salad Tomato
Cucumber
30
30
Tea Tea Milk
Sugar
50
5
Poha Rice Flakes
Potato
Ground Nut
Fat
30
70
20
5
Dinner Boiled rice
Rajmah curry
Rice
Rajmah
Tomato
Onion
Fat
80
30
25
25
10
Chapati Flour
Fat
25
5
Ladies Finger Ladies finger
Fat
100
5
Mango Mango 75
She should also have a glass of milk at night before sleeping. Beverages like coconut
water, lemon water can also be consumed in between meals.
LET’S CHECK THE PROGRESS
1. Mention the physiological changes that take place during pregnancy.
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
81
2. What are some of the common complications of pregnancy?
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
3. Enumerate some of the factors you would consider while planning meals for pregnant
woman.
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
4. Briefly discuss the increased requirement of following nutrients during pregnancy:
• Energy
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
• Iron
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
• Calcium
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
SUMMARY
Pregnancy is physiologically and nutritionally a highly demanding period. Extra food is
required to meet the requirements of the foetus. A woman prepares herself to meet the
nutritional demands by increasing her own body fat deposits during pregnancy. Both the
quality and the quantity of diet is important. Small frequent meals are recommended to
accommodate the increased requirement of food in nutrients.
KEY WORDS
Amenorrhea- Amenorrhoea is the absence of a menstrual period in a woman of
reproductive age.
Foetus- an unborn offspring of a mammal, in particular an unborn human more than eight
weeks after conception.
82
Gestational weight gain (GWG)- The amount of weight a pregnant woman gains between
the time of conception and the onset of labour.
LMP-last menstrual period.
Mammary gland-an organ in a woman's breast that produces milk to feed a baby.
PICA- craving for certain food and non-food items.
Placenta-The placenta is a flattened circular organ in the uterus of pregnant mammals that
nourishes and maintains the foetus through the umbilical cord. This cord is the main link
from the foetus to the placenta. Through it, the placenta provides oxygen and nutrients to
the growing baby and removes waste products.
Prenatal period-It is the time between conception and birth.
REFERENCES
➢ Pitkin, 1976. Nutritional support in obstetrics and gynecology. Clinical Obstetrics and
Gynecology 19(3): 489–513.
➢ Lain, Kristine & Catalano, Patrick. (2008). Metabolic Changes in Pregnancy. Clinical
obstetrics and gynecology. 50. 938-48. 10.1097/GRF.0b013e31815a5494.
➢ Soma-Pillay, Priya & Nelson-Piercy, Catherine & Tolppanen, Heli & Mebazaa,
Alexandre. (2016). Physiological changes in pregnancy. Cardiovascular Journal of
Africa. 27. 89-94. 10.5830/CVJA-2016-021.
➢ ICMR. Nutrient requirements and recommended dietary allowances for Indians. A
report of the expert group of the Indian Council of Medical Research, National
Institute of Nutrition, Hyderabad. 2010.
➢ NIN. Dietary Guidelines for Indians- A Manual. Indian Council of Medical Research,
National Institute of Nutrition, Hyderabad, 2011.
➢ Gopalan C, Rama Sastri BV, Balasubramanian SC. ICMR. Nutritive Value of Indian
Foods. Indian Council of Medical Research, National Institute of Nutrition,
Hyderabad. 1989.
➢ Food & Nutrition for senior Students; Education Planning Group; Arya Publishing
House.
➢ An Advanced Text-book on Foods & Nutrition; Vol II; M. Swaminathan; BAPPCo.
➢ Fundamentals of Foods & Nutrition; S.R. Mudami, M.V. Rajagopal; Wiley Eastern
Limited.
➢ Applied Nutrition; R. Rajalakshmi; Oxford & IBH.
➢ Chadha, R., & Mathur, P. (2015). Nutrition: A Lifecycle Approach. 1st Ed. Orient
BlackSwan.
83
LESSON 7
NUTRITION DURING LACTATION
INTRODUCTION
Like in pregnancy, adequate nutrition of the mother during lactation is of vital
importance since during the first few months of life, the infant derives all the nutrition from
the mother’s milk. The child does not need anything over breast milk for the initial six
months. Generally, the child is breastfed for six to nine months. As the mother has to
nourish a fully developed and rapidly growing infant, she needs extra nutrients to meet the
baby’s needs in addition to her own requirements. Any inadequacies in her diet influences
both the quantity and quality of milk secreted, though the effect on quantity is more.
OBJECTIVES
After going through this lesson, you will be able to
❖ Understand the nutritional implications of the phase of lactation.
❖ Describe the physiological changes during lactation.
❖ Plan a balanced diet for pregnant and lactating woman by taking into consideration
various factors.
LACTATION
Though lactation is a normal physiological process, it makes considerable
nutritional demands on the mother. The physiological developments for lactation begin
during the later part of pregnancy. Apart from the growth and development of mammary
glands, energy reserves are laid down in the form of fat in the body of the mother and this
may become available in part to provide the extra energy during lactation.
The demands on the mother during lactation are greater than during pregnancy,
because the mother nourishes a fully developed and rapidly growing baby whose food
needs are increased day by day. She must have accumulated a store of nutrients in readiness
for satisfactory breast feeding. If the mother is known to have gone through pregnancy
successfully on a faulty and an insufficient diet, it means that she has freely drawn upon
her own tissue to build her baby and she will continue to do so as long as she nurses her
baby. In such cases, it is essential that the maternal diet be rectified, in order that she and
her infant may be saved from malnutrition and its consequences.
The diet of nursing mothers in poor Indian communities does not differ appreciably
from that consumed by them during pregnancy. With the exception of cereals, that is
consumed in slightly increased amounts, there is often no other change in the diet.
84
According to survey a report only a small percentage of them were consuming milk. The
diet of a nursing mother in India suffers from the same draws back as the diet consumed
by them while they were pregnant. Unlike pregnancy, the woman who is breast feeding her
baby requires not only large quantities of building and protective foods, but also requires
additional energy yielding foods to facilitate the formation and copious secretion of breast
milk.
Unfortunately, the prevalent diet in lower and even middle class is lacking in energy
yielding and protective foods. In India, it is customary to breast feed for prolonged periods,
extended till second or even third year. This is done in the belief that nursing prevents
another pregnancy, although, the mother frequently becomes pregnant again. She continues
to suckle the baby until the new one arrives. Most of our women are thus in a continuous
state of lactation throughout the childbearing period of their lives. Studies carried out
among lactating women revealed that when they were given extra amounts of body building
foods, they produced a large amount of breast milk for their infants. Direct evidence of the
amount of milk these women can produce is difficult to get, but the indirect evidence of its
insufficiency is in the form of inadequate weight gain of the baby after the fourth month.
Many mothers can produce 700ml of milk a day during the period of six months to a year
and 100-150 ml during the second year. On the other hand, it is fortunate that despite a
faulty and insufficient maternal diet, the quality of breast milk does not suffer. It compares
well with that of nursing mothers consuming excellent diets in other parts of the world. It
can only be explained by assuming that the Indian nursing mother’s keeps up quality by
withdrawing nutrients from her own bones, blood and muscles for the formation of milk,
since her own diet is inadequate in providing the nutrients required for satisfactory milk
production. It may well be, that there is a limit even for the continuous withdrawal of
nutrients from the maternal body and this may result in deterioration of quality and
reduction in quantity of the milk. The quality of the milk, however, will be affected in
severe maternal malnutrition and the concentrations of vitamin A, B and C is lower than
the well-fed women. The concentrations of iron and calcium, however, seems normal.
ANATOMY OF THE BREAST
The breast structure includes the nipple and areola, mammary tissue, supporting connective
tissue and fat, blood and lymphatic vessels, and nerves.
• The mammary tissue – This tissue includes the alveoli, which are small sacs made of
milk-secreting cells, and the ducts that carry the milk to the outside. Between feeds,
milk collects in the lumen of the alveoli and ducts. The alveoli are surrounded by a
myoepithelial, or muscle cells, which contract and make the milk flow along the ducts.
• Nipple and areola – The nipple has an average of nine milk ducts passing to the
outside, and also muscle fibers and nerves. The nipple is surrounded by the circular
pigmented areola, in which are located Montgomery's glands. These glands secrete an
85
oily fluid that protects the skin of the nipple and areola during lactation and produce
the mother's individual scent that attracts her baby to the breast. The ducts beneath the
areola fill with milk and become wider during a feed, when the oxytocin reflex is active.
Figure 7.1 Anatomy of breast
PHYSIOLOGY OF LACTATION
Hormonal changes markedly increase breast areola and nipple size. During pregnancy
oestrogen secreted by the placenta bring about rapid development of glands in the breasts.
Large quantities of progesterone change the glandular cells to actual secreting cells. By the
time the baby is born breasts reach a degree of development capable of producing milk.
Yet, oestrogen and progesterone, despite their developmental effects on breast inhibit the
actual formation of milk until after the baby is born. Thus during pregnancy, the placental
hormones inhibit the secretion of lactating hormones by the pituitary gland. With the
sudden expulsion of placenta during delivery the source of placental hormones is removed
and secretion of lactogenic hormones is increased which bring about production and
secretion of milk. The process of milk
production and secretion occurs in two
distinct stages.
Prolactin reflex
Prolactin is necessary for the secretion of milk
by the cells of the alveoli. The level of
prolactin in the blood increases markedly
during pregnancy and stimulates the growth
and development of the mammary tissue, in
preparation for the production of milk.
However, milk is not secreted then, because
progesterone and oestrogen, the hormones of Figure 7.2: Prolactin reflex
86
pregnancy, block this action of prolactin. After delivery, levels of progesterone and
oestrogen fall rapidly, prolactin is no longer blocked, and milk secretion begins.
When the baby sucks the breast, nerve impulses are passed up the spinal cord to the
hypothalamus which stimulates anterior pituitary leading to the secretion of prolactin.
Prolactin is carried via the bloodstream to the alveoli in the breasts where it stimulates
production of milk by the alveoli (Figure 4). The prolactin level is highest about 30 minutes
after the beginning of the feed, so its most important effect is to make milk for the next
feed. During the first few weeks, the more a baby suckles and stimulates the nipple, the
more prolactin is produced, and the more milk is produced. This effect is particularly
important at the time when lactation is becoming established. More prolactin is produced
at night, so breastfeeding at night is especially helpful for keeping up the milk supply.
Prolactin seems to make a mother feel relaxed and sleepy, so she usually rests well even if
she breastfeeds at night.
Oxytocin reflex or let-down reflex
The oxytocin reflex is also sometimes called
the “let-down reflex” or the “milk ejection
reflex”. Oxytocin is produced more quickly
than prolactin. It makes the milk that is
already in the breast flow for the current feed
and helps the baby to get the milk easily.
When the baby sucks, nerve impulses are
passed to the posterior pituitary producing
another hormone, oxytocin. Oxytocin
contracts the muscle cells around the alveoli,
squeezing out milk and propelling it down to
the nipples.
Oxytocin starts working when a mother expects a feed as well as when the baby is
suckling. The reflex becomes conditioned to the mother's sensations and feelings, such as
touching, smelling or seeing her baby, or hearing her baby cry, or thinking lovingly about
him or her. If a mother is in severe pain or emotionally upset, the oxytocin reflex may
become inhibited, and her milk may suddenly stop flowing well. If she receives support, is
helped to feel comfortable and lets the baby continue to breastfeed, the milk will flow again.
It is important to understand the oxytocin reflex, because it explains why the mother and
baby should be kept together and why they should have skin-to-skin contact.
COMPOSITION OF BREAST MILK
Breast milk contains all the nutrients that an infant needs in the first 6 months of life,
including fat, carbohydrates, proteins, vitamins, minerals and water. It is easily digested
and efficiently used. Breast milk also contains bioactive factors that augment the infant's
Figure 7.3: Oxytocin reflex
87
immature immune system, providing protection against infection, and other factors that
help digestion and absorption of nutrients. Mother’s milk is not only nutritionally adequate
but also easy to digest, particularly for the new-born. The milk secreted in the first few
days, however, differs in appearance and composition from the milk secreted later. Small
quantities of thick, yellowish viscous fluid known as colostrum is secreted by the mother
for few days after delivery. Colostrum is rich in antibodies and Vitamin A. After a few days
of lactation, the mother starts secreting larger amounts of comparatively less viscous and
whitish milk known as ‘mature milk’ Table 7.1 below gives the composition of Breast
Milk.
Colostrum is the special milk that is secreted in the first 2–3 days after delivery. It
is produced in small amounts, about 40–50 ml on the first day (12) but is all that an infant
normally needs at this time. Colostrum is rich in white cells and antibodies, especially IgA,
and it contains a larger percentage of protein, minerals and fat-soluble vitamins (A, E and
K) than later milk. Vitamin A is important for protection of the eye and for the integrity of
epithelial surfaces, and often makes the colostrum yellowish in colour. Colostrum provides
important immune protection to an infant when he or she is first exposed to the micro-
organisms in the environment, and epidermal growth factor helps to prepare the lining of
the gut to receive the nutrients in milk. It is important that infants receive colostrum, and
no other feeds, at this time. Other feeds given before breastfeeding is established are called
Prelacteal feeds.
Milk starts to be produced in larger amounts between 2 and 4 days after delivery,
making the breasts feel full; the milk is then said to have “come in”. On the third day, an
infant is normally taking about 300–400 ml per 24 hours, and on the fifth day 500–800 ml.
From day 7 to 14, the milk is called transitional, and after 2 weeks it is called mature
milk.
Table 7.1: Composition of Breast Milk
Nutrients Amount/ 100ml
Energy 65 Kcal
Protein 1.1g
Carbohydrate 7.4g
Fat 3.4g
Calcium 28mg
Iron Negligible
Vitamin A 41 mcg retinol
Thiamine 0.02 mg
Riboflavin 0.02 mg
Niacin --
Vitamin C 3mg
Source: Gopalan et al (1989)
88
NUTRITIONAL REQUIREMENTS OF LACTATING MOTHER
Nutritional requirements are considerably higher during lactation than during
pregnancy. During the first four to six months of life, the infant doubles the weight gained
during the nine months of gestation. The milk produced in the first four months of lactation
constitutes an amount of energy that is equivalent to the total energy expenditure of
gestation. The WHO expert committee assumed the optimal daily milk output of mother’s
milk to be 850 ml. This would provide 600 Kcal., 10.2 g protein, 290 mg calcium, 0.25 to
3.1 mg iron, 420 mcg Vitamin A, 22 to 44 mg ascorbic acid, 1.6 mg niacin, 0.52 mg
riboflavin, 0.12 mg thiamine, 9.0 mcg folic acid, and 0.2 mcg vitamin B12. The efficacy of
conversion of food energy into milk solids is believed to be about 80 per cent, while that
of protein about 50 per cent and that of calcium about 30 per cent. The efficiency of
absorption and secretion of dietary vitamins in milk is not known.
It is, therefore, evident that the lactating mother will need extra amounts of all
nutrients at levels somewhat greater than those present in milk, depending on the efficiency
of incorporation in milk of the nutrients present in the diet. The ICMR Nutrition Expert
Committee assumed the average amount of milk secreted by lactating mother in India and
other developing countries to be 600 ml. It is therefore extremely important for the lactating
mother to take adequate nutrients so that she can not only nourish her child but also
maintain her own nutritional status.
Thus, nutritional needs are increased during lactation:
o For sufficient breast milk production.
o For providing adequate nutrients to the infant.
o To meet the mother’s daily needs
The nutritional requirements of nursing mother suggested by ICMR group is
discussed below and given in Table 7.2.
Energy-The nutritional recommendations for lactating women are somewhat
empirical and essentially based on the volume and composition of the milk produced. The
lactating mother needs an additional amount of 600 KCal during the first six months of
lactation and for the next six months, she requires an additional 520 KCal. This extra
amount can be supplied by whole grain cereals, pulses, milk, curd and its products, fruit
juices, soups, vegetables etc.
Protein-The increase in protein requirements during lactation is minimum
compared to energy requirements. The requirement is at its highest when lactation reaches
its maximum, but it is a need which should be anticipated and planned during pregnancy.
The nursing mother needs about 13-19 g of protein over and above her normal
89
requirements. The additional requirements during lactation can be obtained by including
protein rich foods like milk and milk products, egg, meat, fish, poultry and cereal pulse
combination. However, if the energy intake is low, protein will be used for energy
production.
If the protein intake is insufficient, the concentration of casein in milk may be
inadequate. Casein is an important nutritional component of milk, and it is needed for the
absorption of calcium and phosphate in the gut of the infant and has immunomodulatory
functions.
Vitamins-The concentration of some vitamins in breast milk depends on their
levels in the mother, and deficiencies in the mother can lead to deficiencies in the infant.
This is particularly relevant for thiamine (B1), riboflavin (B2), and vitamins B6, B12, E and
A, and consequently an increase in their intake is recommended during lactation.
Fat-soluble vitamins
Vitamin A
It is involved in the photochemical reactions of the retina, it is an antioxidant, and
has antimicrobial properties. The vitamin A content in milk decreases as lactation
progresses. The additional need of vitamin A during lactation is based on the amount
secreted in mother’s milk. Additional need of vitamin A during lactation is calculated on
the basis of vitamin A secreted in milk, which is 350 mcg of retinol per day. Hence ICMR
has recommended an additional allowance of 350 μg/d of retinol i.e. a total of 950 μg/d per
day. The intake obtained with a balanced diet is adequate and supplementation is not
necessary.
Vitamin D
Vitamin D deficiency is fairly frequent in pregnant and lactating women. Mothers
that have restricted diets, such as strict vegetarians, and those with limited exposure to ultra
violet radiation (mothers with limited exposure to sunlight, with dark skin, or that wear a
veil) may have very low plasma levels. In the absence of any experimental data, no definite
additional intake has been suggested.
Vitamin E
The concentration of vitamin E in breast milk is sensitive to maternal intake, so the
maternal diet must be assessed and supplemented if intake is inadequate.
Water-soluble vitamins
The concentration of water-soluble vitamins in milk depends to a great extent on
maternal levels, so that deficiencies in the mother can lead to deficiencies in the infant.
90
Vitamin C
The additional need of 40 mg vitamin C has been calculated on the basis of vitamin
C secreted in milk in an average yield of 850 ml/day in a well-nourished mother.
Vitamin B6 (pyridoxine)
In the early weeks of life, the vitamin B6 stores accumulated during pregnancy are
crucial in maintaining adequate levels in breastfed children. The manifestations of vitamin
B6 deficiency in infants also depend on its severity, although in general it presents with
neurologic symptoms and different forms of dermatitis. Additional intake of vitamin B6’ is
recommended to the tune of 0.5mg/d.
Vitamin B1, B2 and B3
The additional need of thiamine, riboflavin and niacin is based on the additional
energy intake. The recommended intake according to ICMR is given in table 7.2.
Vitamin B12 (Cyanocobalamin)
Vitamin B12 concentrations in the milk of well-nourished mothers are adequate.
However, its levels are low in mothers that are strictly vegetarian (vegan), are malnourished
or have pernicious anaemia, even if they do not show signs of deficiency. In these cases, it
is important that mothers receive a vitamin B12 supplement the entire time they are
breastfeeding, as vitamin B12 deficiency in the infant can have short- and long-term
neurological effects. ICMR has recommended 1.5 μg /day.
Folic acid
The recommended concentration of folic acid in breast milk can be easily achieved
through dietary intake or supplementation, if needed. Additional intake of folic acid
recommended is 100mcg/ day.
Minerals: Compared to vitamins, the concentrations of minerals do not seem to be
correlated to maternal intake, except for iron and iodine. Copper and zinc concentrations
seem to correlate strongly to maternal stores in the liver during the third trimester of the
pregnancy, and maternal intake has little influence on them, although their bioavailability
in milk is very high. Iodine, iron, copper, magnesium and zinc have a high bioavailability
in breast milk. The selenium content is strongly influenced by the mother's diet. The ICMR
Nutrition Expert Committee recommended an additional 600mg of calcium, i.e. a total of
1200mg calcium during lactation. This can be provided by extra milk and milk products,
cereals and green leafy vegetables. If calcium and protein are adequate in the diet,
phosphorus is also bound to be adequate.
Iron
Iron supplementation is usually recommended to make up for losses sustained
during childbirth, although it must be noted that women that practise exclusive
breastfeeding usually experience amenorrhoea for a minimum of six months and thus do
91
not lose iron through menstruation during that time. Therefore, it could be said that
breastfeeding exerts a protective effect against maternal iron deficiency. Some amount of
iron is secreted in milk, but otherwise milk is a poor dietary source of iron. No additional
requirements have been advised by ICMR Nutrition Expert Group. Because of lactational
amenorrhea, 1 mg. of iron which would have otherwise been lost, is saved and this would
compensate for the iron secreted in milk.
Table 7.2: RDA of nutrients for Pregnant and Lactating Woman
Nutrient Sedentary Activity Moderate Activity Heavy Activity
0-6
months
6-12
months
0-6
months
6-12
months
0-6
months
6-12
months
Energy
(kcal/d)
1900+600 1900+520 2230+600 2230+520 2850+600 2850+520
Protein (g/d) 74 68 74 68 74 68
Visible fat
(g/d)
30 30 30
Calcium (g/d) 1200 1200 1200
Iron (mg/d) 21 21 21
Vitamin A
(μg/d)
Retinol 950 950 950
β-
carotene
7600 7600 7600
Thiamine
(mg/d)
1.0+0.3 1.0+0.2 1.1+0.3 1.1+0.2 1.4+0.3 1.4+0.2
Riboflavin
(mg/d)
1.1+0.4 1.1+0.3 1.3+0.4 1.3+0.3 1.7+0.4 1.7+0.3
Niacin (mg/d) 12+4 12+3 14+4 14+3 16+4 16+3
Vitamin B6
(mg/d)
2.5
Ascorbic acid
(mg/d)
80
Dietary folate
(μg/d)
300
Vitamin B12
(μg/d)
1.5
Source: ICMR (2010)
92
DIETARY CONSIDERATIONS
• Meals are planned according to the nutritional requirements which includes needs for
the mother and for milk production. A modification of normal basic diet is worked out
for a nursing mother. Additional amounts of protein and energy foods are included in
this diet. In most regions, it is customary to feed the nursing mother, additional amount
of fat (ghee), which supplies energy and vitamin A or some special preparations
(Halwa, Ladoos of Methi, sonth, garden cress seeds) which contain sources of protein,
iron, calcium and vitamin B. Besides, green leafy vegetables and at least two servings
of citrus fruit make up the demand of other vitamins.
• Condiments should be sparingly used, since, apart from being harmful, if used in
excess, they may give a flavour to the milk which may be repulsive to the baby.
• Besides three large meals, two smalls in between meals may be planned to meet the
increased requirements.
• Fluid intake should be adequate to meet the requirements for milk production.
• Socio-economic status of the family should be considered, and the selection of food
stuffs should be according to the budget of the family e.g. groundnuts, pulses-cereals
may be taken instead of meat and milk products for protein sources. Similarly, green
leafy vegetables may be selected instead of egg and meat products for bringing down
the cost of the diet.
• Variety should be provided in terms of colour, texture and flavour.
• Likes and dislikes of the mother should be taken into consideration.
• Age of the mother be taken into consideration. An adolescent mother, who has not
completed her own growth, will need additional food for her own growth
requirements.
• The food should be served in a pleasant atmosphere.
• Since some of the medicines can be absorbed into the mother’s blood stream and
secreted in the milk, use of medication should be under medical supervision.
SAMPLE DIET PLAN
Balanced diets for a lactating mother (adult woman) is given in table 10.2 A and B, which
may be referred while planning diets.
A day’s diet for a lactating mother belonging to low SES doing hard work.
Recommended Dietary Allowance
Energy -- (2850+600) = 3450 Kcal
93
Protein -- 74g
Calcium -- 1200 mg
Meal Menu Food Stuffs Amount (g)
Breakfast Tea Milk
Sugar
25
5
Paushtik Roti Wheat flour
Besan
Fat
160
40
10
Coriander
Chutney Coriander
Onion
100
25
Jaggery
Jaggery 50
Midday Guava Guava 100
Atta, Besan
Laddoo Besan
Wheat flour
Ghee
Sugar/Jaggery
20
30
20
30
Lunch Methi Roti
Chana Dal
Wheat flour
Methi
Fat
Chana Dal
Onion
200
80
10
40
30
Butter milk
Butter milk 200
Dinner Rice
Chapati Rice
Wheat flour
100
100
Moong Dal Moong
Onion
Fat
40
30
5
Potato Subzi Potato
Onion
Fat
100
30
5
Salad Tomato 100
94
KEYWORDS
• Colostrum- thick, yellowish substance secreted from a mother’s breasts in the first
postpartum days; rich in immunoglobulins
• Foremilk- watery, translucent breast milk that is secreted first during a feeding and is
rich in lactose and protein; quenches the infant’s thirst
• Hind milk- opaque, creamy breast milk delivered toward the end of a feeding; rich in
fat; satisfies the infant’s appetite
• Lactation- process by which milk is synthesized and secreted from the mammary
glands of the postpartum female breast in response to sucking at the nipple
• Let-down reflex-release of milk from the alveoli triggered by infant suckling
• Prolactin- pituitary hormone that establishes and maintains the supply of breast milk;
also important for the mobilization of maternal micronutrients for breast milk
LET’S CHECK THE PROGRESS
1. What is colostrum?
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
2. Discuss some of the factors you would consider while planning meals for lactating
woman.
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
3. Briefly discuss the increased requirement of the following nutrients during lactation:
• Energy
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
• Protein
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
95
• Calcium
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
REFERENCES
➢ Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students
and Allied Health Professionals. Geneva: World Health Organization; 2009.
➢ ICMR. Nutrient requirements and recommended dietary allowances for Indians. A
report of the expert group of the Indian Council of Medical Research, National
Institute of Nutrition, Hyderabad. 2010.
➢ NIN. Dietary Guidelines for Indians- A Manual. Indian Council of Medical Research,
National Institute of Nutrition, Hyderabad, 2011.
➢ Gopalan C, Rama Sastri BV, Balasubramanian SC. ICMR. Nutritive Value of Indian
Foods. Indian Council of Medical Research, National Institute of Nutrition,
Hyderabad. 1989.
➢ Food & Nutrition for senior Students; Education Planning Group; Arya Publishing
House.
➢ An Advanced Text-book on Foods & Nutrition; Vol II; M. Swaminathan; BAPPCo.
➢ Fundamentals of Foods & Nutrition; S.R. Mudami, M.V. Rajagopal; Wiley Eastern
Limited.
➢ Applied Nutrition; R. Rajalakshmi; Oxford & IBH.
➢ Chadha, R., &Mathur, P. (2015). Nutrition: A Lifecycle Approach. 1st Ed. Orient
BlackSwan.
96
LESSON 8
NUTRITION FOR ELDERLY
People worldwide are living longer. Today, for the first time in history, most people
can expect to live into their sixties and beyond. By 2050, the world’s population aged 60
years and older is expected to total 2 billion, up from 900 million in 2015. Today, 125
million people are aged 80 years or older. By 2050, there will be almost this many (120
million) living in China alone, and 434 million people in this age group worldwide. By
2050, 80% of all older people will live in low and middle-income countries. The pace of
population ageing around the world is also increasing dramatically.
OBJECTIVES
After going through this lesson, you will be able to
❖ Understand the nutritional implications of the aging.
❖ Describe the physiological changes associated with ageing.
❖ Plan balanced diet for elderly by taking into consideration various factors.
AGEING
Ageing is an irrevocable and inevitable multidimensional process that involves
physiological, pathological, biological, psychological, immunological and social
changes which influence the nutritional requirements. WHO defines old age as the period
of life starting from 65 years of age. According to this chronological definition, age ranges
of young old (65-74 years), middle old (75-84 years), and very old (≥85 years) have been
defined. These age- related changes are neither linear nor consistent. However,
consequently increase the incidence of co-morbidities and diminish the capacities of daily
life.
Figure 8.1: The vicious cycle of aging
97
At the biological level, ageing results from the impact of the accumulation of a wide variety
of molecular and cellular damage over time. This leads to a gradual decrease in physical
and mental capacity, a growing risk of disease, and ultimately, death. Beyond biological
changes, ageing is also associated with other life transitions such as retirement, relocation
to more appropriate housing, and the death of friends and partners. In developing a public-
health response to ageing, it is important not just to consider approaches that ameliorate
the losses associated with older age, but also those that may reinforce recovery, adaptation
and psychosocial growth.
PHYSIOLOGICAL CHANGES ASSOCIATED WITH AGEING
▪ Changes in Posture and Appearance-Postural changes in aging include a stooping
forward, with head tilted backward and knees, hips and elbows flexed. Body
proportions change with age as shoulder width decreases and the chest, pelvic and
abdominal areas increase in diameter. Some structural changes are due to bones losing
calcium and some are due to changes in musculature. The trunk shortens as inter
vertebral distances narrow. The centre of gravity moves from the hips to the upper
torso, affecting balance.
▪ Changes in Body Composition-Body composition also changes with age. By age 75,
body fat increases and body water decreases. Lean body mass also declines. The arms
and legs lose body fat while the abdomen and hips gain body fat. Men lose more
subcutaneous fat than women. This loss of fat leads to decreased cold tolerance. The
blood supply to the skin decreases, with the greatest decrease occurring in the arms and
legs.
▪ Changes in the Respiratory System-As the muscles become more rigid, inspiratory
and expiratory muscle strength decreases, causing reductions in both ventilation and
vital capacity. The functional capacity of the lungs drops by about 50%, resulting in
dyspnoea with exertion or stress. Alveoli decrease in number and size.
▪ Changes in the Cardiovascular System-With age, blood pressure rises, accompanied
by reduced elasticity and lumen size of blood vessels, which impair the function of the
vessel. The chances of experiencing myocardial infarction, hypertension, congestive
heart failure or stroke increase with age.
▪ Changes in the Gastrointestinal System-Tooth loss is not, as is commonly believed,
a normal age-related change. Many individuals keep their teeth intact throughout the
life span. The tooth enamel does thin and teeth do become brittle. Saliva production
decreases in the mouth, causing xerostomia (dry mouth). The taste buds decline in
number and there is a decrease in the sense of taste, thought to be greater in men and in
smokers. With increased age, gastrointestinal symptoms such as indigestion, heartburn
and epigastric discomfort increase. The gag reflex decreases. In the oesophagus,
98
decreased peristaltic activity and relaxation of the lower oesophageal sphincter cause
delayed emptying and an increased risk of aspiration. Delayed gastric emptying and a
difficulty in digesting large quantities of food is also seen. The musculature of intestine
weakens, peristalsis decreases, and nerve sensation diminishes. Constipation is a
frequent complaint in the elderly. The production of the enzyme’s trypsin, amylase and
lipase decreases, leading to poor tolerance of high-fat meals and poor absorption of fat-
soluble vitamins. There lease of insulin also decreases.
▪ Changes in the Genitourinary System-Kidney size decreases with age, the number
of nephron units decreases and the amount of extracellular fluid increases. Due to a
reduction (up to 50%) in renal blood flow, the glomerular filtration rate decreases. The
capacity of the bladder decreases by about half in old age; frequency and nocturia
increase. It is more difficult to empty the bladder due to weakening of the bladder and
perirenal muscles.
▪ Changes in the Musculoskeletal System-Bone loss starts which is influenced by diet,
hormonal changes and physical activity. Joints also change due to cartilage loss. Since
muscle cells are not replaced in the adult, muscle mass decreases. Demineralization of
bone has been observed commonly in aged persons. This condition is known as
Osteoporosis.
NUTRITIONAL REQUIREMENTS OF ELDERLY
Nutrition offers the means to improve health and well-being and among the
predictive factors of successful aging, nutrition appears as one of the major determinants.
Whereas adequate nutrition plays a major role in a healthy lifestyle that maintains bodily
and mental functioning, inadequate nutrition contributes to a loss of function and to the
development and progression of disease.
From 25 years of age the basal metabolism decreases about 2 per cent for each
decade. The decline in the basal metabolism is less in person who remains healthy and
pursue vigorous activity in their later years. The lower metabolic rate and reduced activity
in elderly stage reduces the energy requirement.
Table 8.1: Percentage decrease in energy requirement (%)
Age (years) Decrease in energy requirement (%)
20-39 0
40-49 5
50-59 10
60-69 20
70 and above 30
99
For the calculation of energy requirement, ICMR has recommended the decrease in energy
requirement with age as shown in Table 8.2.
Table 8.2: Energy requirement of Elderly with different Body Weights
(Kcal/24hrs.)
Body Weight
(Kg)
Age 60 years and above
Males Females
Sedentary Moderate Sedentary Moderate
40 -- -- 1477 1737
45 1590 1870 1553 1627
50 1688 1985 1630 1917
55 1786 2101 1706 2007
60 1883 2216 1782 2097
65 1981 2331 1860 2187
70 2079 2446 1936 2277
75 2177 2565 -- --
Source: ICMR (2010)
Energy-The energy (calorie) intake should be adjusted to maintain the body weight
constant in case of old people with normal body weight. In case of obese people, the
calorie intake should be adjusted to reduce the body weight gradually to about normal
level.
Protein- In view of the tendency to eat less as a result of decreased appetite and poor
digestive capacity, old people are likely to consume less protein and suffer from protein
deficiency. Hence, adequate intake of protein should be ensured. Since milk is a good
source of protein besides vitamins and minerals, adequate quantities of milk should be
consumed. The daily protein intake should be at least 1.0 to 1.4g per kg body weight.
Fat- The diet should contain sufficient amount of fat, as it is a concentrated source of
energy. Most of this fat should be in the form of vegetable oils, which are rich in
essential fatty acids.
Vitamins and minerals- Mild deficiencies of several vitamins occur frequently among
old people. It is, therefore, essential to ensure adequate intakes of all essential vitamins.
If the diet consumed does not contain adequate amount of all vitamins, a multivitamin
tablet providing the daily requirements of different vitamins should be taken daily.
Requirements of thiamine, riboflavin and niacin are based on energy
requirements. Ascorbic acid requirement is 40 mg. Folic acid, vitamin B12 and vitamin
B6 are required about 200 mcg, 1.0 mcg and 2.0 mg respectively.
Calcium and iron deficiencies occur frequently as absorption of these nutrients is less
efficient than in normal adults. The calcium intake should not be less than 500mg and
100
the iron intake 28mg. Since even mild anaemia affects the health of old people due to
less efficient circulation of blood, iron intake should be adequate to prevent anaemia.
Fluid- The importance of adequate fluid intake so as to maintain the volume of urine
excreted at a minimum of 1.5 litres is not generally recognized. Water can be consumed as
such or in the form of butter milk, fruit juices, porridge, soups etc. during summer season.
Dietary fibre- Adequate intake of soft indigestible carbohydrate (roughage) in the form
of raw/soft cooked vegetables and fruits should be ensured to avoid constipation. The senile
intestinal mucosa does not tolerate fibre from mature vegetables and bran of cereals.
Finally, a balanced diet is the best way to avoid deficiencies and maintain health. If
in subgroups of the elderly population an adequate nutrition cannot be achieved, low dose
dietary supplements and/or fortified foods and beverages can contribute to improve nutrient
intake.
NUTRITIONAL AND HEALTH CONCERNS
Cardiovascular Disease-Cardiovascular disease remains the most common cause of death
of older adults. This category includes chronic ischemic heart disease, congestive heart
failure, and arrhythmia. Ischemic heart disease. Lifestyle modifications like reducing salt
intake, abstinence from alcohol and smoking/tobacco, maintaining ideal body weight and
regular physical activity can help in preventing cardiovascular disease.
Diabetes- Diabetes represents a spectrum of metabolic disorders, which has become a
major health challenge worldwide Diabetes is a condition primarily defined by the level of
hyperglycaemia giving rise to risk of micro vascular damage (retinopathy, nephropathy and
neuropathy). Diabetes mellitus basically produces changes in the blood vessels and hence
can affect almost every part of the body. It is associated with reduced life expectancy,
significant morbidity due to specific diabetes related micro vascular complications,
increased risk of macro vascular complications like ischemic heart disease and stroke and
diminished quality of life Diabetes is common in the elderly population. By the age of 75,
approximately 20% of the population are afflicted with this illness.
Hypertension-Hypertension, a major contributor to atherosclerosis, is the most common
chronic disease of older adults. Reducing stress, eating healthy, and exercising will help
keep blood pressure under control.
Malnutrition-Poor nutritional status and malnutrition in the elderly population are
important areas of concern. Malnutrition is often due to one or more of the following
factors: inadequate food intake; food choices that lead to dietary deficiencies; and illness
that causes increased nutrient requirements, increased nutrient loss, poor nutrient
absorption, or a combination of these factors. Nutritional inadequacy in the elderly can be
the result of one or more factors—physiologic, pathologic, sociologic, and psychologic
101
(Figure 8.2). Prevention and early intervention are the key because it is difficult to reverse
the effects of under nutrition and weight loss.
Figure 8.2: Factors influencing nutritional inadequacy in the elderly population
Malnutrition and unintentional weight loss contribute to progressive decline in health,
reduced physical and cognitive functional status, increased utilization of health care
services, premature institutionalization, and increased mortality.
Figure 8.3: Contributing factors and health outcomes associated with under
nutrition
102
Cancer-Cancer is a chronic disease, and like any other chronic medical condition, cancer
patients have families, jobs, businesses and other commitments. Therefore, it is important
to cure the cancer if possible, and if not curable, then control the symptoms to improve
quality of life and prolong one’s life by a few months. In the elderly, cancer is one of the
predominant causes of mortality and morbidity, and its incidence increases with ageing.
Sixty percent of all cases with cancer, and 70% of cancer-related deaths occur in patients
aged 65 years and over.
Anaemia-Geriatric anaemia is a very prevalent condition in India. It significantly increases
the mortality and morbidity in the elderly. Symptoms of fatigue, pale skin, and decreased
cognitive ability are easily attributed to getting old. This may not always be the cause. With
the world's elderly population rising so rapidly, it is evident that the percentage of elderly
living with anaemia is also expected to increase both in the developed and developing
countries. Untreated anaemia in elderly can be detrimental, because it is associated with
increased mortality, poor health, fatigue, and functional dependence and can lead to
cardiovascular and neurological complications.
Cognitive Ageing-Mild short-term memory loss, word-finding difficulty, and slower
processing speed are normal parts of aging that are often noticeable by age 85. Changes
from normal brain aging can affect driving safety and increase risk for financial
exploitation. These changes can also reduce capacity to understand complicated medical
information.
Depression-Depression is not a normal consequence of aging. Grief can be a normal
response to life events that occur with aging such as bereavement; retirement/loss of
income; and loss of physical, social, or cognitive function from illness. Depression is even
more common among institutionalized older adults and those with disabilities.
Alzheimer’s disease-Alzheimer’s disease is an irreversible, progressive brain disorder that
slowly destroys memory and thinking skills, and, eventually, the ability to carry out the
simplest tasks or loss of the ability to carry on a conversation and respond to the
environment. It is the most common type of dementia. It involves parts of the brain that
control thought, memory, and language and can seriously affect a person’s ability to carry
out daily activities.
DIETARY CONSIDERATIONS
• The diet should be nutritionally balanced, and emphasis should be given on the
adequate intake of protein, calcium, vitamin and fibre, which are liable to be deficient
in most cases.
• Since chewing may be problem, the meals prepared should be soft and one or two
liquid items may be given such as soup, dal or gruel so that swallowing becomes easy,
Salads can be grated. As such the food should be well cooked. Chapati can be made
103
thicker if chewing is a problem, and if needed they may be soaked in milk, soup or
other liquid preparation.
• An adequate intake of calcium should be ensured to compensate for its losses due to
gradual demineralization of bones associated with ageing.
• With the advancement of age, the capacity to digest and tolerate large
meals often decreases. Therefore, the quantity of food given at a time needs to be
decreased. The number of meals may be increased as per individual’s tolerance.
• Soft unavoidable carbohydrates should be included in the diet to avoid constipation.
• Excess consumption of sweets, rich desserts should be cut to a minimum as they
provide empty calories but take away the appetite.
• Calorie intake should be adjusted to keep the body weight constant in case of normal
old people.
• For poor appetite low bulk, calorie-dense foods, prepared and served in an appetizing
way should be planned. These people may be given mid-morning or mid-afternoon
snack.
• Factors such as likes and dislikes, special needs, fear of new foods, food prejudices,
lack of money, poor appetite should be considered.
Table 8.3: Some suggested Menu for Elderly
BREAKFAST LUNCH DINNER
Broken wheat porridge
Poached Egg
Toast with butter
Papaya
Lentil dal
Palak Saag
Grated salad
Chapati
Fruit custard
Ghia Kofta curry
Rice/Chapati
Boondi raita
Grated Carrot
Salad
Wheat flour/ Suji halwa
Milk
Chapati
Dal Palak
Curd
Chapati/Rice
Vegetable Kadhi
Papaya
Upma with crushed
groundnuts
Banana
Rice
Sprouted Black Gram
Cooked carrots
Khichri
Milk/curd
Tomato Salad
Carrots
Rice and green gram
Porridge with milk
Chapati
Chana Dal
Grated Carrot
Rice
Sambhar
Grated carrot
Bread/Toast
Scrambled Egg
Milk
Vegetable fried rice
Coriander chutney
Curd
Rice
Egg curry
Dry Vegetable
104
When meal time appetite is poor, in-between nourishments may be planned.
LET’S CHECK THE PROGRESS
1. What are some of the physiological changes associated with ageing process?
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
2. Suggest some dietary modifications for the elderly having dental problems.
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
KEYWORDS
Malnutrition- A deficiency or excess (or imbalance) of energy, protein and other nutrients,
which causes measurable adverse effects on tissue/body form (shape, size, composition),
function and clinical outcome. Can encompass both overnutrition and undernutrition, but
often used to refer to undernutrition only.
Undernutrition-A clinical syndrome characterised by weight loss associated with
significant depletion of fat stores and muscle mass. It is also known as protein energy
undernutrition.
SUMMARY
During old age there is decline in the function and efficiency of various organs and
systems of the body. There is reduced physical activity and lowered rate of metabolism.
Various physiological changes accompany the process of aging. All this influences the
nutritional requirements. They are prone to both undernutrition and overnutrition.
Therefore all the factors must be considered while planning diet for elderly.
REFERENCES
➢ Chadha, R., & Mathur, P. (2015). Nutrition: A Lifecycle Approach. 1st Ed. Orient
Black Swan.
➢ ICMR. Nutrient requirements and recommended dietary allowances for Indians. A
report of the expert group of the Indian Council of Medical Research, National
Institute of Nutrition, Hyderabad. 2010.
105
➢ NIN. Dietary Guidelines for Indians- A Manual. Indian Council of Medical Research,
National Institute of Nutrition, Hyderabad, 2011.
➢ Gopalan C, Rama Sastri BV, Balasubramanian SC. ICMR. Nutritive Value of Indian
Foods. Indian Council of Medical Research, National Institute of Nutrition,
Hyderabad. 1989.
➢ Food & Nutrition for senior Students; Education Planning Group; Arya Publishing
House.
➢ An Advanced Textbook on Foods & Nutrition; Vol II; M. Swaminathan; BAPPCo.
➢ Fundamentals of Foods & Nutrition; S.R. Mudami, M.V. Rajagopal; Wiley Eastern
Limited.
➢ Applied Nutrition; R. Rajalakshmi; Oxford & IBH.
➢ Caring for the Older Patient, Part II: Age-Related Anatomic and Physiologic Changes
and Pathologies, Steves AM, Dowd SB and Durick D. J. Nucl. Med. Technol. 1997;
25:86-97.
➢ Cancer in the elderly. Cinar., D and Tas D. North Clin Istanb. 2015; 2(1): 73–80.
➢ Malnutrition in the Elderly: A Multifactorial Failure to Thrive. Evans, C. Perm J. 2005
Summer; 9(3): 38–41.
106
107
UNIT 3
NUTRITION DURING CHILDHOOD AND ADOLESCENCE
Lesson 9: Nutrition during Infancy
Lesson 10: Nutrition for Pre-Schoolers
Lesson 11: Nutrition for School aged Children
Lesson 12: Nutrition during Adolescence
108
109
LESSON 9
NUTRITION DURING INFANCY
INTRODUCTION
Infancy is the period of life from birth of child through the completion of first year
of life. Adequate nutrition is very essential during this stage, as the foundation for further
growth is laid. Apart from this infancy is a fragile period of life. During infancy there are
special needs of the body that have to be fulfilled.
OBJECTIVES
After you have read this lesson you will be able to
❖ Understand the benefits of breast feeding.
❖ Describe the importance of supplementary feeding.
❖ Plan nutritious weaning foods for infants.
INFANCY
Infancy is the time for rapid growth and development. The body weight of an infant
at birth is doubled in about 5 months and within a year it becomes three times his birth
weight. Similarly, there is an increase in the length of an infant from 50 cms at the time of
birth to 75 cms within a year i.e. by the first birthday, a child becomes one and a half times
longer than what he was at the time of birth. No time in life such a spurt in growth occurs
which corresponds with high energy and nutrient requirement per unit of body weight. The
average growth pattern of an infant is given in Table 9.1.
Table 9.1: Average Weight and Height Increment during the First Year.
Age (months) Weight increment per week (g)
0-3
4-6
7-9
9-12
200
150
100
50-75
Source: (Ghosh, 1992)
The full term infant is able to digest proteins, emulsified fats and simple
carbohydrates such as lactose. During the first few months the starch splitting enzymes are
not produced at a satisfactory rate and gastric acidity is also low. The stomach capacity of
the infant and the ability to digest various food components changes rapidly as the infant
grows. The brain develops rapidly during foetal life, infancy and early childhood. The
110
increase in the number of brain cells is most rapid during foetal life and 5-6 months after
birth. If malnutrition is severe in this period, the number of brain cells are greatly reduced
and once the critical period of cell division has passed, adequate diet cannot bring about an
increase in cell numbers.
NUTRITIONAL REQUIREMENTS
Generally, an infant depends completely on mother’s milk for the first few months.
Thus, adequate nutrition is essential for the lactating mother. If adequate nutrition is
maintained during lactation, there will be proper milk production not only in terms of
quantity, but also in terms of quality. Thus, the mother’s milk will contain all the nutrients
particularly the vitamins and minerals in adequate amounts which will be able to meet the
needs of the child.
The recommended allowances by ICMR Expert group (2010) are given in Table
9.2. The requirements of different nutrients are briefly discussed below:
The calorie intake by infants is based on energy intake of normally growing infants
on breast milk adlib (to any desired extent). These allowances are in the nature of guideline
for feeding infants; who for various reasons cannot receive breast milk. The quantity of
breast milk needed to meet these levels of energy would be 850 ml up to three months of
age and 1200 ml. between three and six months of age. The calorie intake for growth is
higher during the first half of the year when growth is most rapid. Break milk provides 50-
60% energy from fat (about 25-27 g/day). Therefore, foods, which are used as substitutes,
when breast milk is not available, should ensure this high proportion of fat.
Weaning diets must provide 25% energy as fat, primarily to reduce bulk: 10%
energy from invisible fat and 15% energy (about 17g/day) from visible fat should be aimed
at. About half of the energy expenditure is accounted for by the basal metabolism in order
to regulate body temperature and maintain high level of metabolic activities, besides, those
infants who are active and cry a lot, use more energy. The ICMR recommended that
calories allowance for infants below 6 months of age is 92 KCal per kg body weight and
for 6 to 12 months old 80 KCal per kg body weight. When these energy intakes are
compared with those of an average adult, which are 40-50 calories per kg body weight, the
high-energy needs of an infant become apparent. The relatively high need for energy in an
infant is understandable, when we note than an average infant doubles his birth weight in
the first five months of life and triples it by the end of the first year.
The infant’s requirement for protein is also highest per unit of body weight during
the first six months. Allowance of protein can, however, be computed from a knowledge
of the protein content of breast milk and the volume of milk consumed by healthy infants,
whose growth rates are normal. Since infants in India get supplementary feeding based on
vegetables proteins, it is recommended that protein allowances for infants between 6-12
months of age may be made in terms of both breast milk and vegetable proteins, each
111
contributing equally to total protein intake. Protein requirements are not only for increase
in body size, but also is for an increase of the percentage of body protein. The ICMR has
recommended an intake of 1.16g per kg body weight for 0-6 months of age and for 7-12
months as 1.69g per kg body weight.
Losses of iron in infants are not precisely known and amounts needed to replace
these losses are therefore difficult to determine. Taking into account the need for growth,
the daily intake for 0-6 month old is recommended at 46 mcg/kg/d and 87 mcg/kg/d for 6-
12 month old. Iron supplements should be given from 4-6 months for premature infants.
The calcium requirements for young infants can be computed from calcium intake through
breast milk of healthy infants, who are solely breast-fed. On this basis an intake of
500mg/day has been recommended. Calcium in human milk is 50-60% retained in the
body, whereas the calcium in cow’s milk is 25-30% retained. Since the content is much
higher, the net retention is about the same. Others minerals are adequately met by human
or other milk sources.
Table 9.2: RDA for Indian Infants
Nutrient Age
0-6 months (weight 5.4
kg)
6-12 months (weight 8.4
kg)
Energy (kcal/d) 92 80
Protein (g/d) 1.16 1.69
Visible fat (g/d) - 19
Calcium (g/d) 500 500
Iron (mg/d) 46 mcg/kg/d 5
Vitamin A (μg/d)
Retinol 350 350
β-carotene - 2800
Thiamine (mg/d) 0.2 0.3
Riboflavin (mg/d) 0.3 0.4
Niacin (mg/d) 710 650
Vitamin B6 (mg/d) 0.1 0.4
Ascorbic acid (mg/d) 25 25
Dietary folate (μg/d) 25 25
Vitamin B12 (μg/d) 0.2 0.2
Source: ICMR (2010)
Vitamin A intake has been recommended as 350 mcg vitamins A on the basis of
vitamin A ingested by breast-fed infants in well-nourished communities. The ICMR does
not give any recommendation for vitamin D, E and K for infants. Vitamin D can be
synthesised in the body in adequate amounts on sufficient exposure to sunlight. Vitamin C
intake is recommended on the basis of vitamin C ingested by breastfed infants in well-
nourished population. About 25 mg has been recommended.
112
Thiamine and riboflavin intake up to six months of life can be calculated on the
basis of the amounts of vitamins ingested through breast milk. Niacin has been calculated
on the basis of 6.6mg/1000 kcal, as is done for adult subjects. Relevant data on which
requirements for infants can be based are scanty, except those relating to the vitamin
B6 content of breast milk. However, B6 is stored in the liver during foetal growth and is
apparently drawn up on during early infancy. Therefore, an intake of 0.1 mg during first
half infancy and 0.4 mg during the second half of infancy has been recommended. The
intake of folate in breastfed infants is about 25 mcg/day. Most of the folate in breast and
cow’s milk is available for absorption. Hence the intake has been recommended at 25 mcg
daily. An intake of 0.2 mcg of vitamin B12 prevents abnormal haemopoiesis in infants,
hence the recommended. Except for Vitamin D, all the Vitamins are adequately supplied
in human milk from healthy mother. Human milk will supply the ascorbic acid level but
infants fed on other milks require vitamin C supplementation.
For Carbohydrates, there is no recommended allowance. Lactose accounts for 38-
40% of the calories in human milk. Since lactose content of cow’s milk is lower, lactose or
simple carbohydrates is already added to the commercial formulas or to the fresh cow or
buffalo’s milk. About 40-50% of calories in human milk and other commercial milk
products are supplied by fat. Low fat artificial feedings are contra-indicated. Since it is
difficult to achieve sufficient calories intake for satisfactory weight gain. Water need is met
by mother’s milk, but when other food is given to the infant, boiled and cooled water should
be given, to enable the body to excrete the end products of metabolism. Additional water
need must be met in summer season.
BREAST FEEDING
The food par excellence for the newborn baby is mother’s milk. The practice for
breast-feeding is universal in India except among the so-called educated women and the
high socio-economic group. Fortunately even the poorly nourished mother is able to nurse
her child satisfactorily at least during the first few months of life. The composition of breast
milk with regard to its nutrient content is not seriously affected by the diet of the mother
under ordinary circumstances. The milk of poorly nourished mother may contain less of
water-soluble vitamins, but the infant usually gets enough for its requirements.
Bottle-fed infants getting the best baby foods and food containing more of protein,
calcium etc. are not found to grow faster than breast fed babies. Mother’s milk is deficient
only in iron (Table 9.3), but the baby is born with adequate body stores of iron which can
last for the first 3-4 months, hence the child does not need additional supplements during
this period. Vitamin C is another important nutrient which is present in limited amounts in
the mother’s milk. Even then it is sufficient to meet the requirements of the infant for first
few months, as mother’s milk is fed as such without any loss of vitamin C due to heating.
Unfortunately the trend towards bottle-feeding is increasing. Most upper class mothers do
113
not nurse their babies beyond the first few weeks. Often the bottle is introduced right from
the birth.
The more unfortunate phenomenon is that nursing women from low socio–
economic status, particularly in urban areas, take to bottle feeding in imitation of the upper
class women. As they are not able to provide milk or baby food in adequate quantities and
are also ignorant about the significance of proper hygienic conditions required, their baby
suffers. The increasing trend towards bottle feeding results in increased infant sickness and
mortality due to
o Ignorance of the basic rule of sanitation,
o Insanitary preparations and poor handling of bottles and milk formula
o Use of milk substitutes poor in nutrient content
o Over-dilution of infant formula with water.
IMPORTANCE OF BREAST MILK
There is no substitute for mother’s milk to fulfil the needs of the baby. Mother’s
milk is the right food for the baby’s digestive system. Other foods are not tolerated by the
infant that well, because of the poorly developed digestive system of the baby. The
advantage of breast-feeding are following:-
1. It is more readily assimilated than the cow’s milk, for it is produced to suit the baby’s
digestive system.
2. Breast milk is free from contamination and adulteration and is available at the right
temperature without any effort.
3. Breast milk contains proteins, which protect the child to some extent against infections
like mumps, measles, polio, some kinds of pneumonia etc.
4. Babies fed on breast milk are less likely to develop constipation and certain common
infant allergies.
5. Breast feeding does make possible an exceptionally close and harmonious relationship
that is enjoyable and satisfying to both infant and mother.
6. It is easily digestible and fats are better emulsified. There is a higher proportion of
lacto albumin protein, which is better digested than casein (protein in animal milk).
7. It has a lower protein and mineral content, which is more suitable for babies.
8. It contains more vitamin A, C and E than cow’s milk. Iron in breast milk is better
absorbed than cow’s milk.
STARTING BREAST-FEEDS
Soon after birth if feasible, the mother should put the baby to breast. The secretion
for a first few days is yellowish colostrum. It has a high protein and vitamins A content and
114
confer immunity to certain infections during the first few months. It aids the development
of digestive enzymes. Therefore, it is important that the newborn is breast fed from the first
day and gets colostrum. After the birth of the baby, the milk supply rapidly increases from
about 100 ml on the second day, to about 500 ml in the second week. During the first 5-6
months, healthy infants consume 600-800 ml per 24 hours, but there are wide variations
between babies. In poorly nourished mothers, it rarely exceeds 400 ml.
WHEN BREAST-FEEDING IS NOT ADVISABLE?
Breast-feeding must be discontinued when:
a) The mother suffers from chronic illness such as tuberculosis, epilepsy, insanity, and
chronic fevers, severe anaemia, nephritis or cardiac disease.
b) The infant is weak or unable to nurse due to cleft palate or harelip.
c) Temporary stoppage of breast-feeding is advisable when the mother acquires an acute
infection, which the baby has not yet got.
There are no other reasons to stop breast–feeding. It must be continued even if the
child has loose stools, vomiting or has any minor or major illness.
Substitute for Breast Feeding- If the quantity of breast milk is not adequate or
when no milk is available, the infant is artificially fed, partially or wholly, as the case may
be.
Table 9.3: Comparison of nutrients present in various milk (per 100 ml)
Nutrient Human
milk
Cow’s
milk
Buffalo’s
milk
Toned
milk
Water (g) 88 87.5 81 -
Energy (kcal) 65 67 117 58
Protein (g) 1.1 3.2 4.3 3.2
Carbohydrate
(g)
7.4 4.4 5 4.7
Fat (g) 3.4 4.1 6.5 3.0
Calcium (mg) 28 120 210 118
Source: Gopalan et al (1989)
Table 9.3 shows that the other milk are richer in protein as compared to human milk
and lower in carbohydrates. Therefore, judicial dilution with boiled water and addition of
sugar will bring the composition near to that of human milk. If cow’s milk is to be given
to an infant, dilution to the tune of 1part water and 1 part milk and should be gradually
reduced, so that the infant gets whole cow’s milk at the end of 6 months. The amount of
sugar that has to be added be 1 teaspoon in the first week to 4 teaspoons by 6 months in a
day. Buffalo’s milk is richer than cows’ milk because of greater fat content. It can be
partially skimmed, diluted with water and then sugar added to it.
115
This will reduce vitamin A content of the milk and therefore Vitamin A supplement
be added. Some babies are not able to digest buffalo’s milk because it forms thick curd in
the stomach, which is difficult to digest. Some infants who cannot tolerate animal milk i.e.
they are allergic to it, can take groundnut or soybean milk. Soybean milk is more
satisfactory from nutritional point of view; infants brought up on this milk with suitable
vitamins and minerals added to it, grow quite well.
As far as possible bottles should not be used for feeding the baby, instead traditional
methods of feeding with a ‘katori’ and ‘spoon’ should be employed. However, if due to
some reasons, the bottle has to be used one should boil the bottle and the nipple before
every feed to ensure that the nipple and bottle are sterile and do not become a source of
infection.
Since, the top milk is always boiled before giving to the child. The little amount of
vitamin C present is lost, hence care must be taken to ensure that the foodstuffs containing
vitamin C such as orange juice and tomato juice are also given to the child.
Special Infant Food- Dried or powdered milk is cow’s milk, which has been
rapidly dried to powder at a high temperature by various industrial processes. It is much
used in infant feeding by addition of 8 times its weight with water. They are processed such
that they resemble to human milk in composition. Vitamin C should always be given to
infants fed with dried milk formula. Dried skim milk should not be used as a sole food for
infant feeding. In situations where no other form of milk is available, such milk may be
used with vitamin A supplementation. This may by the case in poor and very poor sections,
where dried skim milk be distributed free of cost.
Condensed milk contains 20% of sugar and dilution of it proportionally reduces
proteins, fat and mineral content of the milk. Further the sugar may cause intestinal
irritation and upset. Therefore, such commercial preparations cannot be recommended for
infant feeding.
SUPPLEMENTARY FEEDING (WEANING)
Breast milk alone cannot supply the nutritional needs beyond 6 months of infant’s
life and therefore, supplementary foods are needed. It is generally seen that till 6 months
the infants thrives well on mother’s milk and it is only after that if adequate supplements
are not fed, the infant shows signs of inferior growth development, and symptoms of under-
nutrition.
“The process of introducing supplementary foods along with the mother’s milk to
an infant is known as weaning or supplementary feeding”.
This is a gradual process. It starts when supplementary foods are introduced to the
chid and continues until the child stops taking breast milk all together. Any other food
except mother’s milk is known as supplementary food.
116
During the first six months if breast milk is adequate as shown by continued and
satisfactory growth of the infant, no other food is necessary. If it is possible to provide food
hygienically to the infant fish liver oil can be given from the first month and fruit juice
from the second month onwards. These must necessarily be given if the infant is artificially
fed. Most Indian mothers can produce enough milk only for 3-4 months and, by this time
the baby gains weight about 5 Kg. and requires 500-600 kcal. per day for his needs.
Therefore, it is essential to add semi-solids to the feeding of infant to cover up the increased
requirements.
WEANING
Weaning is the process of gradually introducing foods other than breast milk in the
child’s feeding schedule. This process starts with any food besides mother’s milk. It is
introduced in the child’s diet and is completed only when the child has been entirely put
off the breast. It has two advantages, firstly, it meets the increased energy and nutritional
requirements for the infants after 6 months and secondly, it makes the infant gradually
accustomed to new tastes and textures of different food, which helps the infant to adjust to
family food in early childhood and, thereafter. By the time the child is a year old, he should
get used to the normal family diet. Table 9.4 gives a broad outline of the type of food that
can be given to an infant.
Whenever new foods are introduced in a child’s diet the following points must be kept in
mind-
1. Introduce only one food at a time.
2. The weaning process must be started with small quantities of food. The amount of food
can be increased gradually, as the child develops a liking for the food.
3. The consistency of foods should be in accordance with the age of the child. For very
young infants, liquid supplements should be given and their consistency can be
gradually shifted from liquid to semi liquid and then to solid as the age advances.
4. The child should never be forced to eat. If the child dislikes a particular food that food
may be removed from the diet for the time being and can be reintroduced at a later
stage.
5. The child’s food should not be spicy, fried foods should also be avoided.
6. Variety should be introduced in the child’s diet to make it more appealing. As the child
grows older, the colour, flavour, texture and shape of the food should be given special
consideration to attract the child’s attention.
7. The parents should not show personal prejudices and dislike towards any food, so as to
make the child learn to eat all the foods.
117
By the age of 6-7 months, well-mashed fruits like banana, ripe papaya, ripe and
sweet mango, and ripe tomato can be given. If needs be, the mashed pulp should be passed
through a sieve to obtain a puree which is free from lumps and fibres, other fruits like apple,
apricot, pears can be given, after stewing and making into puree. Fresh juice of orange or
coconut water can be given to very young infants.
Cereal can be given in gruel form. First cereals are well cooked to a soft texture and
passed through a sieve to give a smooth consistency. Milk can be added to form gruel.
Starting 1-2 teaspoon, it can be increased gradually to 50g or ½ cup by 3-4 weeks. Fruit
puree can be added to cereal gruel and fed. Rice conjee, dalia, suji, ragi are common
suggested cereal gruels. Sago is a pure starch food, hence not very suitable. For, those, who
can afford ready to eat cereals like Cerelac, Farex, Nestum, Balamul, and others, can
purchase them from the market. Direction for their use is on the container.
By the age of 7-9 months, seasonal vegetables can be introduced. Potato is
available throughout the year and is a common dietary item. It can be boiled, mashed, and
softened with milk. Carrot, peas, spinach, yellow pumpkin are boiled with enough water,
(vegetable juice should not be discarded) and puree is prepared. Just a pinch of salt is added.
It should be started with 1-2 teaspoon and gradually increased to 50g (1/2cup). Soups of
vegetables have negligible food value. If soup is thickened with mashed potatoes or roasted
cereal flour, the nutritional value is enhanced. The quantity of additional foods started, can
be increased gradually.
By the time the infant is 9-10 months of age, variety of home cooked food can be
offered combinations; rice and dal (parboiled rice or home pounded rice is preferred),
strained cereal gruels with Milk, bread, Rusk, biscuits, soaked in milk, washed green gram
dal khichri, kheersujihalwa, boiled sweet potatoes mashed in milk. Others fruits in mashed
form. In families belonging to higher income group or even middle class, custard and
simple pudding can occasionally form the diet of the infant; parched grains have high
acceptability and digestibility. Puffed rice is commonly used as weaning food. Parched
grain is combination of cereal be made into powder form, and stored for few days. This
“ready mixture” can be made into gruel with water or milk and fed. Buttermilk or dal water
and jaggery can also be incorporated in preparation of the gruel.
Fermented foods such as idli, dhokla, are very common in South India and Gujrat,
respectively (both foods are made from rice and dal). Fermentation increases the
digestibility and improves on nutritional quality. Sprouting increase digestibility and
nutritional value. Both starch and protein are broken down to simpler products. Some of
the bound iron is converted to more readily available form. Green gram, Bengal gram, and
other legumes are sprouted and ground to paste and strained. This can be mixed to roasted
cereal flour and cooked to a gruel consistency. If chapattis are made these can be soaked in
milk/dal. Curd or soups should be added to suit the chewing ability of the infant. By this
118
time the infant is sitting and likes to nibble on biscuit, rusk, crisp chapatti piece or a stick
of carrot.
When the infant is 10-12 months of age, all the above-mentioned food can be given
in well-cooked form, and the amount is gradually and slowly increased. Finely ground soft
cooked meat and fish can be given in non-vegetarian households. By the end of the year,
boiled, poached or scrambled whole egg can also be started.
Table 9.4: Weaning Foods for Infants
Infant’s
age
Foodstuffs Form in which
given
Amount to be given Type of
supplement
6-7 months Fruit juices
Green leafy
vegetables
Juice mixed with
a little sugar
Soups in milk
Start with 1-2 spoons
and increase to about
30-50 ml
Start with 1-2 spoons
and increase to about
50 ml
Liquid
Liquid
7-8 months Cereals Cooked in water
or milk
Cook about 2 tsp of
cereal in a cup of milk,
e.g. suji kheer.
Semi-solid
8-9 months Egg yolk
Starchy
vegetables
and fruits
Half boiled egg
yolk
Boiled and
mashed potato
with butter or
milk
Mashed banana
with milk
Start with ½ tsp and
increase to 1 yolk.
Start with small amount
and increase to 40-50g
Semi-solid
Semi-solid
9-10 months Vegetables
and pulses
Well cooked
vegetables, thin
khichri
Starting with small
amounts increase the
quantity gradually
Semi-solid
10-12
months
Whole egg,
meat
Vegetables,
fruits
Soft boiled egg,
scrambled egg,
custard
Well cooked
Chopped
One egg
Starting with small
quantities and by
increasing the amount
gradually
Semi-solid
Solid
119
Table 9.5 : Salient Features of Broad Age Related Guidelines for Weaning Process
6 months
Mash all food
Give semi-solid food; do not over dilute
Start with one or two teaspoons
Over 3 to 4 weeks increase to 50-60 g or half a cup (or one banana) a day.
Continue breastfeeding
7 to 9 months
Same as for 6 months
Amount of food is gradually increased
Variety of food is increased
Continue breastfeeding
9 to 12 months
More variety of household food can be added.
Can eat almost everything cooked at home (softened and without spices)
Continue breastfeeding
12 months to 18 months
Needs about 1000 calories or roughly half the amount that the mother eats
Continue breastfeeding.
To establish good habits, remember that each infant is an individual and there are
no set rules about feeding, like adults, babies do have liking for a particular food and eat
more on some days than other days. Forced feeding should be avoided. Mealtime should
be relaxed and pleasant. New food should be started at a time when baby is hungry, healthy
and happy. The food is well administered in the gradual order of liquid, semi–solid then,
chopped and lumpy, Seasoning should be limited to salt, sugar, and jaggery or lime juice.
WEANING FOODS, WHICH CAN BE PREPARED AT HOME
Khichri
Rice 50 g
Lentil 25 g
Spinach 50 g
Oil 2 teaspoons
Salt to taste
Method- Cook rice and dal together and mash. Boil spinach, mash and strain. Add
this spinach puree, salt and heated oil to the rice dal mixture, stir and serve.
Bengal Gram Dal Khichri
Rice 50 g
Green gram dal 25g.
Roasted Bengal gram 50g
Green leafy vegetables 25 g
120
Oil 1 teaspoon
Salt to taste
Method- Boil and mash rice and green gram dal, boil, mash, and strain, the spinach.
Add spinach powered, Bengal gram and salt to the rice and dal mixture and cook for a few
minutes, Season with oil.
Khichri and Wheat Dalia
Broken wheat 50 g
Lentil 50g
Potato in amounts desired
Any green vegetable in amounts desired
Oil 3 teaspoons
Salt to taste
Onion 1 small
Ginger 2 g
Bay leaf and cardamom (optional) 1 each
Method- Clean and wash Dalia and lentil separately and vegetables. To boiling add
onion, ginger, bay leaf, cardamom and Dalia, Half cook, then add lentil and vegetables and
cook until soft. Season with salt and oil.
Khichari of Rice, Dal, and Vegetables
Rice 50 g
Dal lentil 25g
Potato in amounts desired
Any vegetable in amounts desired
Oil 3 teaspoons
Salt to taste
Onion 5 g
Ginger (optional) 2 g
Bay leaf (optional) 1
Method- Clean and wash rice and lentil separately and cut vegetables small. To
boiling water add a piece of onion, ginger, bay leaf, cardamom and rice. Half cook, then
add lentil and vegetables and cook until soft. Season with oil and salt. This can be made
without vegetables also.
Rice Upma
Rice 25 g
Green gram dal 25 g
Onion 1 large
Any vegetable 10 g
Mustard ½ teaspoon
Groundnut oil 4 teaspoons
121
Salt to taste
Water 2 cups
Method- Roast rice and dal and grind into granules. Cook green gram dal with ¾
cup water and mash. To hot oil, add mustard, onion and fry. Then add water and salt. Add
the rice granules and the vegetable to the water and stir. Cook for 10 minutes and add the
green gram day paste. Drumstick leaves may also be use instead of vegetables.
Sago Conjee
Sago 25 g
Roasted Bengal gram 25 g
Jaggery 25 g
Water cups 2
Method- Roast sago and powder Bengal gram. Add sago to one and half cups of
boiling water and cook. Prepare a batter of Bengal gram powder in 1 cup of water and pour
it into the cooked sago, stir in continuously. Cook for 10 minutes. Add jaggery and cook
for 5 minutes again.
Porridge of Wheat Dalia
Broken wheat 50 g
Sugar 15 g
Milk 50 g
Method- Roast wheat Dalia and add to boiling water containing 2 bay leaves and
cook until soft. Add sugar and boiled milk.
Ragi Porridge
Ragi flour roasted 50 g
Bengal gram dal flour (roasted) 4 teaspoons
Groundnut cake powder (roasted) 4 teaspoons
Jaggery 20 g
Method- Boil jaggery solution. Mix ragi, and Bengal gram flour and make a batter
with hot water, Pour the batter slowly into the jaggery solution stirring continuously. Boil
for 10-15 minutes, serve warm.
Bajra Infant Food
Bajra 50 g
Green gram dal 3 teaspoons
Skim milk powder 2 teaspoons
Groundnut 2 teaspoons
Til seeds 1 teaspoon
Sugar or salt to taste
122
Method- Clean and dehuskbajra. Roast and powder bajra, green gram dal,
groundnut and til seeds. Mix all the powders together with skim milk powder and store in
an airtight container. Whenever required mix the powder with boiling water or milk to the
desired thickness Add salt or sugar.
Chapatis with Atta, Bengal Gram, Powder and Leafy Vegetables
Atta 3 parts
Bengal gram flour 1 part
Green leafy vegetable as desired
Sweet Dal
Rice 30 g
Red gram dal 60 g
Spinach 30 g
Jaggery 60 g
Method- Roast and powder rice and red gram dal. Mix the two and make a batter
with cold water, boil, mash and strain spinach. Mix the batter and spinach puree with
jaggery syrup and cook for a few minutes.
Khaman Dhokla
Bengal gram dal 50 g
Black gram dal 25 g
Rice 50 g
Amaranth leaves 50 g
Curd 25 g
Oil 1 teaspoon.
Salt to taste
Mustard seeds a few
Method- Soak Bengal gram dal, black gram dal, and rice separately for few hours.
Grind them separately and mix. Add curd and salt and ferment the mixture overnight. Add
amaranth leaves, season with and mustard seeds and pour the batter into Idli moulds and
steam.
Laddoos of Groundnut and Gingelly Seeds.
Groundnut 25 g
Jaggery 25 g
Gingelly seeds half of groundnut and jaggery
Method- Roast groundnut and gingerly seeds. Pounds them with jaggery make
small balls with the mixture.
Panjiri
Wheat flour (atta) 75 g
123
Jaggery or sugar 15 g
Oil or ghee 2 teaspoons
Method- Roast wheat atta in oil till it turns light brown, Add jaggery and mix well.
Sattu
Soak barley overnight, Dry it a little, roast and grind. Mix with sugar or jaggery according
to taste.
Suji Kheer
Suji 25 g
Sugar 10 g
Milk 250 ml.
Method- Boil milk and add suji. Cook on a slow fire till it becomes semi-solid. Add
sugar.
Rice Kheer
Rice 25 g
Sugar 10 g
Milk 250 ml.
Method- Clean, pick and wash rice. Boil milk, add rice and cook till it becomes
semi-solid. Add sugar.
Rice Conjee
Rice 100 g
Water 400 to 500 ml.
Salt 1.5 to 2 g
Method- Clean, pick and wash rice. Add rice to water and cook till soft, adding salt.
Poha (Leftover Rice)
Rice
Onion
Potato or other vegetables
Method- Fry the onion till it becomes brownish in oil and add cumin and mustard
seeds. Add vegetables and cook till tender, adding minimum quantity of water. Finally add
rice, cook for 2 to 3 minutes.
124
A sample day’s diet for an eight months old infant
Meal time Foodstuffs Amounts
6 am Breast milk 150-200 ml
8 am Yolk of soft boiled egg One egg yolk
10 am Rice and moong dal premix in tomato juice 15 g in 50 ml tomato juice
12 noon Cow’s milk 150 ml
2 pm Mashed banana in milk with sugar Half banana
5 pm Cow’s milk 150 ml
7 pm Khichri with curds ½ katori with 2tbsp curds
10 pm Breast milk 150-200 ml
LET’S CHECK THE PROGRESS
1. ‘Infancy is a period of rapid growth spurt’. Explain.
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
2. What are the benefits of breast feeding?
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
3. Explain the following briefly:
• Colostrum
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
• Weaning
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
• Plan five complementary foods for a 10 month old infant belonging to low SES.
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
125
SUMMARY
Infancy is a period of rapid growth and development. Nutritional requirements per
unit body weight are highest during infancy. As mother’s milk is complete food for the
baby, exclusive breast feeding is recommended during first six months of infancy. After
six months complementary feeding is recommended to meet the increasing requirements
of growing infant. Infant foods should be well balanced with the inclusion of a variety of
cereals, pulses, fruits and vegetables.
KEY WORDS
Colostrum- thick, yellowish milk secreted after childbirth for the first few days.
Premature- child born before 37 weeks of gestation.
Weaning- the process of giving food other than the breast milk usually after six months
of age.
REFERENCES
➢ Feeding and Care of Infant and Young Children, Dr. Shanti Ghosh, VHAI, 1992
➢ Fundamentals of Foods and Nutrition; Mudambi; Raja opal, Wiley Eastern Limited
➢ Applied Nutrition; R. Rajalakshami; Oxford and IBH
➢ Essential of Foods and Nutrition; M. Swami Nathan; BAPPCO
➢ Recommended Allowances for Indians, ICMR Publications, 1990
➢ Foods and Nutrition (for senior students); Education, Planning, Group; Arya
Publishing House.
➢ Gopalan S, Puri RK. Breastfeeding and infant growth. Indian Pediatrics 1992,
29:1079-1086.
➢ The Quantity and Quality of Breast milk: Report on the WHO Collaborative Study on
Breastfeeding. Geneva, World health Organisation, 1985.
➢ Weaning from Breast milk to Family Food – A Guide for Health and Community
workers. Geneva, world health Organization and united Nations Children Fund, 1988.
➢ Ghosh S. basic concepts of Supplementary semi-solid feeding. In: Selected Topics in
Infant Nutrition. Eds. Naryanan I, Kumar H, Sachdev HPS. Delhi, SwasthyaGyan
Foundation, 1990, pp 89-92.
➢ Narayanan I. Practical aspects of semi-solid feeding. In Selected Topics in Infant
Nutrition. Eds. Narayanan I, Kumar H, Sachdev HPS. Delhi, SwasthyaGyan
Foundation, 1990, pp 93-100.
126
➢ ICMR. Nutrient requirements and recommended dietary allowances for Indians. A
report of the expert group of the Indian Council of Medical Research, National
Institute of Nutrition, Hyderabad. 2010.
➢ Gopalan C, Rama Sastri BV, Balasubramanian SC. ICMR. Nutritive Value of Indian
Foods. Indian Council of Medical Research, National Institute of Nutrition,
Hyderabad. 1989.
➢ Chadha, R., & Mathur, P. (2015). Nutrition: A Lifecycle Approach. 1st Ed. Orient
BlackSwan
127
LESSON 10
NUTRITION FOR PRE-SCHOOLERS
INTRODUCTION
In the previous lesson we studied about the period of rapid growth i.e. infancy.
Infancy is followed by the pre-school (1-6 years) when the overall rate of growth is less
than that during infancy. Preschool age is marked by rapid physical, social, emotional,
intellectual, motor and language development. The child becomes more active and the
social and environmental influences have a great impact on his food behaviour and eating
pattern. Development of full dentition by the end of two years increase the range of foods
that can safely be eaten. The need for nutrients is increased as growth and development
continues School age is the phase of slow but steady growth and development on all fronts.
OBJECTIVES
After going through this lesson you will be able to
❖ Understand the pattern of development during preschool age.
❖ Plan balanced diets for these children keeping in mind their food behaviour.
PRE-SCHOOL
The care of pre-school children deserve priority as this group is most likely to get
malnourished. They succumb readily where the diet is poor in quality and quantity and
infectious diseases and infestations are widespread. The rate of growth and development
of pre-school children depend to a large extent on the adequacy of the diet consumed by
them. The child not only suffers from deprivation of food but deprivation of mother’s care
and closeness also (common among lower income group). The 1-2 year old child
completely depends on some one for his feeding and care. The change in this respect is not
much from infancy to early childhood. This group has already begun to show a decided
change in appetite and interest in food.
Growth and development – Neither growth nor development takes place at a
uniform rate. This is a long period of very gradual growth. During the second year, the
toddler increases in height by 7-8 cm and gains weight by 3-4 kg. Thereafter until the pre-
adolescent period the annual gain in height are approximately 6-7 cm and in weight 1.5-3
kg. Boys are taller and heavier than girls at each age, except about at 11-12 years, when
girls are usually heavier. As growth proceeds there are changes in the proportion of water,
muscle tissues, fat deposits and skeletal structures. The body water decrease gradually, with
the addition of adipose tissue and of minerals to the bones. By 4 years of age the body
protein content has increased to an adult level of 18-19% of the body weight. At a given
age, girls have a higher percentage of body fat than boys, but, less muscle tissues. The
number, size, and composition of bones changes from birth to maturity.
128
Psychosocial changes also take place. As he steps into the second year he develops
a sense of individuality which is distinct and is reflected in his food behaviour. With
advancing age there is an increasing sense of independence, initiative, imagination and
curiosity.
It has been demonstrated that even minor limitations of nutrient need during the
growing period may prevent the full potential of growth from being attained. However, it
is not height by itself that is of merit, but the completion of growth to the final correct
proportions and the complete development of the child. This is the foundation of good
health in adult years. Therefore a steady gain in height and weight in conformity with his
own pattern is the basic easy criteria for assessment for his nutritional status.
NUTRITIONAL REQUIREMENTS
Data regarding the mean daily nutritional requirements of the pre-schooler as
recommended by ICMR Expert Group Committee (2010) is given in Table 10.1.
Energy
The child needs energy for his growth and activity. The need may vary widely
depending upon the level of growth and activity. Adequate calories must be supplied, if
growth is to occur. When the calorie intake is below the requirement, proteins foods are
used for energy instead of tissue building. As the body weight increases, the calories per
kg of body weight also increases. Therefore the calorie intake is based on age and growth;
for 1-3 years it is 1060 calories and for 4-6 years, it is 1350 calories daily.
Table 10.1: RDA of Nutrients for Preschool Children
Nutrient Age
1-3 year 4-6 year
Energy (kcal/d) 1060 1350
Protein (g/d) 16.7 20.1
Visible fat (g/d) 27 25
Calcium (g/d) 600 600
Iron (mg/d) 09 13
Vitamin A (μg/d)
Retinol 400 400
β-carotene 3200 3200
Thiamine (mg/d) 0.5 0.7
Riboflavin (mg/d) 0.6 0.8
Niacin (mg/d) 8 11
Vitamin B6 (mg/d) 0.9 0.9
Ascorbic acid (mg/d) 40 40
Dietary folate (μg/d) 80 100
Vitamin B12 (μg/d) 0.2-1.0 0.2-1.0
Source: ICMR (2010)
129
Protein
Protein requirements increase with age and growth. The increasing muscle mass
requires a positive nitrogen balance. The basal losses and the additional requirement for
growth have been considered in determining the allowances for protein. An intake of 16.7
g for 1-3 year old, which increases to 20.1 g for 4-6 year olds daily, has been recommended.
Proteins are major constituents of the matrix of the bones and teeth, nails, hair, blood cells
and serum. Every living cell, and all body fluids except urine and bile contain protein.
Protein intake rises with variety and quantity of food, however if the calories are obtained
largely from carbohydrates including soft drinks, sweet and fatty foods, both the quantity
and quality of protein intake suffers.
Fat
Adequate fat is required to provide the extra calories as well as to add calorie
density and reduce bulk in the diet. The linoleic acid requirement is 3 percent of energy.
To provide sufficient energy density and improve palatability of the diet 25g of visible fat
per day has been suggested.
Vitamins
Vitamins are essential for normal growth. Although the requirement is very little
they play an important role in the metabolism of several nutrients.
Vitamin A
Indians take their Vitamin A mainly in the form of β-carotene. Since the body only
utilizes Vitamin A, a factor 0.125 has been used for conversion of β-carotene to Vitamin
A. Therefore the requirement for retinol (Vitamin A) is eight times less than that of
carotene. Animal foods contain pre-formed vitamin A, Retinol. An intake of 400 mcg has
been recommended for 1-6 year olds. The intake can be calculated in terms of vitamin A
in animal foods and carotene in vegetable foods separately and converted to one of the two
by using the factor.
Vitamin D
A great majority of Indian children do not consume foods containing Vitamin D
and in spite of this very few have signs of vitamin D deficiency. This shows that much of
the vitamin D requirements are met from sunlight and the dietary requirements are
probably very small. It promotes absorption of calcium from the intestines, and helps in
mineralization of bones.
Vitamin C
Vitamin C in Indian diets is contributed in a very large extent from cooked
vegetables and very small portion from raw vegetables. Considering losses in cooking and
storage, the requirement has to be doubled. An intake of 40 mg has been recommended by
ICMR.
130
B-Complex vitamins
B-Complex vitamins principally combine with specific proteins to function as part
of various enzyme systems, which are concerned with the breakdown of carbohydrate,
protein and fat in the body. Thus, they are inter-related and intimately involved in the
mechanism, which release energy, CO2 and H20 as the end product of metabolism. Hence,
for every 1000 calorie intake, 0.5 mg. thiamine intake; for every 1000 calorie intake, 0.6
mg riboflavin intake; for every 1000 calorie intake, 6.6 mg niacin intake has been
calculated and recommendations are on this basis. Allowances for pyridoxine (B6), folic
acid, and Vitamin B12 are mainly computed and based on the breast milk content of these
vitamins. The recommended dietary intake of nutrients serves as a guide in planning and
evaluating satisfactory food intake by children.
Minerals
Calcium
Calcium requirements must be met for the growing bones and teeth. Skeletal
deformities that occur during this period are not reversible; hence an intake of 600 mg is
recommended. Adequacy of calcium intake is directly correlated with the intake of milk or
milk products.
Iron
Iron intake should be adequate to meet the needs for growth and increased blood
volume, which can be met by an intake of 9-13 mg daily. To achieve this one must include
iron-rich foods such as eggs, meat, green leafy vegetables, and whole grain cereals.
NUTRITIONAL AND HEALTH CONCERNS
Protein energy malnutrition, micronutrient deficiencies such as vitamin A deficiency
and iron deficiency anaemia are common among preschool children. The primary cause of
malnutrition is a faulty and inadequate diet. Besides diet and socio economic factors
various environmental factors aggravate the dietary deficiencies. These include
▪ Chronic infection
▪ Poor environmental sanitation
▪ Poor insanitary living conditions and
▪ Poor personal hygiene.
Protein energy malnutrition
Protein energy malnutrition (PEM) is a major public health problem in India. It
affects particularly the preschool children (<6 years) with its dire consequences ranging
from physical to cognitive growth and susceptibility to infection. This affects the child at
the most crucial period of time of development which can lead to permanent impairment
in later life. According to World Health Organization, protein energy malnutrition (PEM)
131
refers to “an imbalance between the supply of protein and energy and the body's demand
for them to ensure optimal growth and function”.
The socio-cultural factors play an important role wherein, it affects the attitude of
the care giver in feeding and care practices. The compromised nutritional status of the
mother comes up as a direct determinant in producing a low birth weight baby, worse if the
child is born to a large and poor family. This further worsens the condition with
susceptibility to infections and lack of health care services.In spite of improvement in food
availability and poverty alleviation numerous other determinants play a role in its
causation. The interplay of these determinants and their complementary effect makes it
difficult to isolate one key factor in causing undernutrition.
Vitamin A deficiency (VAD)
Vitamin A is an essential nutrient needed in smaller amounts for normal visual and
immune functions, the maintenance of epithelial cellular integrity, growth, and
development. Vitamin A deficiency is the leading cause of preventable childhood blindness
and increases the risk of death from common childhood illnesses such as diarrhoea. Though
VAD is a multi-casual disorder, episodes of severe disease, poor dietary intake of protein
and vitamin-A rich food, lack of vitamin-A supplementation, poor immunization status,
poor maternal awareness about vitamin-A and high parity, poor maternal education,
socioeconomic status and sanitary practice, male sex, and nutritional stunting were some
of the factors significantly associated with it.
DIETARY CONSIDERATIONS
Eating pattern, behaviour and attitude towards food is part of growing up and
changing phase. Hence, mothers must be educated in this respect. Toddler’s appetite slows
down in line with his slower growth rate as compared to the period of infancy. This should
be taken as ‘small appetite’ for his age rather than ‘poor appetite’. At this age the young
toddler is becoming increasingly aware and intrigued by his surroundings, all of which vie
his attention. He would like to play with his food, feed himself with his hands, refusing the
same food when it is offered on a spoon. This can become an anxious time for the
inexperienced mother, accustomed to the voracious appetite of infancy. Unless the mother
is guided correctly, food and eating may become a battleground between herself and the
child, and may lay the basis for some of the anorexia and emotional upsets related to food
and eating which is often seen in pre-school years. She needs to understand and is able to
enjoy her child’s developing skills and interests, even when he spills milk, splashes food,
squeezes it, she will be less likely to feel frustrated with the result, hence will not worry
over the food which he does not eat.
132
Some of the following considerations should be kept in mind while feeding a pre-
schooler:
i. The diet should be nutritionally balanced. This is important, since the appetite of the
child is small and the nutritional needs are high. To meet such demands nutritionally
well balanced and concentrate foods should be selected.
ii. The child is learning new habits. After one year, all types of foods should be started,
so they by the completion of 2 years, the child can fall in with the main meal pattern
of the family.
iii. At times food items selected for the family can be modified to meet the needs of the
pre-schoolers, so that extra cooking is not required.
iv. Foods easily available and seasonal should be included in the menu. These are less
expensive and more nutritious and tastier.
v. Economic status of the family should be kept in mind.
vi. There should be a variety in terms of taste, texture and colours. The child may be
served food in small attractive containers.
vii. Meal should be planned such, so it can be prepared in the time available, when time
is limited, one dish (e.g. Paushtikroti with dahi or Paushtik khichri with dahi) can
be made as nutritious as several dishes cooked separately.
viii. Meal should be ready to meet the child’s meal timing.
ix. Spicy and strong flavoured foods should be avoided from the child’s menu, as it may
upset his stomach.
x. Sweets, toffees, and chocolates, should be given judiciously, as they provide empty
calories.
xi. Eating time for the child should be pleasant and relaxing.
xii. Small frequent meals should be provided at regular intervals as the pre-schoolers
have a small appetite and short attention span for eating.
xiii. Finger foods are better accepted.
xiv. New foods should be introduced when the child is hungry.
MEAL PLAN
For a 1-2 year old child, the diet differs only slightly from that described earlier for
infants. His vegetables and fruits are mashed or chopped and foods softened, when
necessary. He handles finger foods such as biscuits, rusk, fruits or carrot slice well. By age
of 3 years, he is well introduced to family meal pattern. Sometimes the young toddler would
like to eat one or two food items with delight and shun rest, but soon get settled to normal
meals. Children generally prefer raw vegetables to cooked ones (raw carrots preferred to
cook ones). The most likely method for developing good food habits in children is for the
133
whole family to eat wisely, since children are big imitators. Table 10.2 suggest some menu
for selecting food items for a pre-schooler.
Table 10.2: Suggested Menu for 1-3 years old
Meal Suggested Menus
Breakfast • Fermented wheat flour chapatti, Milk, Jaggery.
• Idli, Curds
• Suji gruel, Egg.
• Poushtikpoha, Milk.
• Butter toast, Boiled egg.
Mid Morning • Banana
• Mango
• Custard
• Orange Juice
• Biscuits
Lunch • Poushtik khichri, Curds
• Chapatti, Lentil, Carrot Potato veg
• Kheer, Poushtik roti, Curd.
Tea • Chirwa, Curd
• Bread /Biscuit, Milk
• Omelette, Milk
• Upma, Milk
Dinner • Chapatti/Rice, Green gram palak
• Chapatti, Meat/veg stew, Kheer
• Khichari, Spinach raita, Salad.
LET’S CHECK THE PROGRESS
1. Discuss the growth and development of preschool children.
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
2. What are the ways by which healthy food habits can be developed among pre-
schoolers?
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
134
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
3. Suggest five interesting and nutritious snacks for preschool children.
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
SUMMARY
Pre-school age (1-6 years) is the phase when the overall rate of growth is less than
that during infancy. Preschool age is marked by rapid physical, social, emotional,
intellectual, motor and language development. Nutrient requirements must be adequately
met to support growth. Foods served should be simple, easy to handle and interesting. All
of these factors should be considered. The diet should be nutritionally balanced. This is
important, since the appetite of the child is small and the nutritional needs are high. To
meet such demands nutritious and concentrate foods should be selected.
KEY WORDS
Peer pressure- influence of peer and schoolmates.
REFERENCES
➢ ICMR. Nutrient requirements and recommended dietary allowances for Indians. A
report of the expert group of the Indian Council of Medical Research, National
Institute of Nutrition, Hyderabad. 2010.
➢ NIN. Dietary Guidelines for Indians- A Manual. Indian Council of Medical Research,
National Institute of Nutrition, Hyderabad, 2011.
➢ Onis MD, Blossner M. WHO global database on child growth and malnutrition.
WHO. 1997. Available from: http://whqlibdoc.who.int/hq/1997/WHO_NUT_
97.4.pdf .
➢ Chadha, R., & Mathur, P. (2015). Nutrition: A Lifecycle Approach. 1st Ed. Orient
BlackSwan
➢ An Advanced Textbook of Nutrition, Vol, II, Dr. M. Swami Nathan.
➢ Fundamentals of food and Nutrition, S.R Mudambi, Rajagopal.
➢ A textbook of Food and Nutrition, Education Planning Group.
➢ Applied Nutrition, R. Rajalakshmi, Oxford and IBH.
135
LESSON 11
NUTRITION FOR SCHOOL AGED CHILDREN
INTRODUCTION
School age is the phase of slow but steady growth and development on all fronts.
Proper nutrition is one of the most important influences on your youngster's well-being. A
varied, balanced diet-containing vitamins, minerals, protein, carbohydrates, and even some
fat-promotes growth, energy and overall health. The nutritional requirement is the same for
boys and girls upto nine years after which girls out do boys and there is a change in some
of the nutrient requirements for boys and girls. Moreover, food preferences are developed
early in life, mostly during early and middle childhood. Once they are established, they are
hard to break. Thus, the earlier you encourage healthful food choices for your child, the
better.
OBJECTIVES
After going through this lesson you will be able to
❖ Understand the pattern of development during school age.
❖ Plan balanced diets for these children keeping in mind their food behaviour.
SCHOOL CHILDREN
Once the child starts going to school, the attention of the parents is diverted to
his/her school activities and thus food may become a secondary matter. The result is that
the nutritional needs of the child are often neglected. If the child was well nourished when
he entered school, the effect of negligence during school years does not show symptoms
for some time.
Growth pattern
Though rate of growth is slow during school years, adequate reserves are laid down
during this period for the rapid growth during adolescence. Hence the age from 6-12 years
is being called the “lull before the storm”. Growth in early school years proceeds at a
moderate rate, although the strenuous activity of this period has a considerable demand on
calorie intake. The yearly increase in height varies from 4.0 to 7.7 cm in boys and 4.9 to
7.2 cm in girls. The increase in height slowly declines after 14th years in boys and the
12th year in girls. The yearly increase in weight varies from 2.5 to 6.6 kg in boys and from
2.3 to 5.2 kg in girls. The yearly weight increase steadily declines after the age of 14 in
boys and 13 in girls.
136
NUTRITIONAL REQUIREMENT
Energy and Protein
The child’s energy requirement increases due to steady increase in growth and
activity. It ranges from 1690 KCal for 7-9 year old to 2190 KCal, for 10-12 year old boys,
while the girls of the same age require about 2010 KCal. Body needs for protein also
increases as these are required for growth and development.
Fat
In terms of visible fat the ICMR has recommended an intake of 5-6 percentage of
total energy from linoleic acid. Considering this the minimum visible fat required has been
estimated to be 12g / day but ICMR has suggested the desirable visible intake for school
going children as 30g/day for children of 7-9 years.
Vitamins
Vitamin A or equivalent carotene requirement increases. According to increase in
age 600 mcg of retinol is required for 7-12 year old. Thiamine, riboflavin, and niacin
intakes are based on calorie intake. An increase in the intake of these is relevant. The
requirement for vitamin B6 is considered to be related to protein intake. 40 mg of vitamin
C is recommended for this group, which includes a margin of 50% loss during cooking.
120-140 mcg of folic acid is recommended, taking into account the bioavailability of the
food folates. Since vitamin B12 is present only in foods from animal origin and Indian diets
are basically vegetarian, a dietary allowance of 0.2-1 mcg per day has been recommended
which also takes into account cooking losses and the uncertainty about the extent of
absorption of vitamin B12. Metabolism of folic acid and B12 are closely related and
deficiency of both the vitamins lead to abnormal haemopoiesis. Vitamin D is required for
proper absorption of calcium. The skin should be exposed to sunlight for about 30 minutes
to one hour for adequate synthesis of vitamin D. Table 11.1 shows the recommended
dietary intakes of nutrients for children (ICMR, 2010).
Minerals
Calcium requirement during this period are the same, considering that throughout
this period a steady and moderate increase in bone length and diameter takes place. A
requirement of 600-800 mg of calcium has been suggested by ICMR. Iron requirements for
10-12 year old is higher due to expanding blood volume and increasing haemoglobin
formation.
137
Table 11.1: ICMR Recommended dietary allowances of school going children
Nutrient Age
Children 7-9 years Boys 10-12 years Girls 10-12 years
Body weight (kg) 25.1 34.3 35.0
Energy (kcal/d) 1690 2190 2010
Protein (g/d) 29.5 39.9 40.4
Visible fat (g/d) 30 35 35
Calcium (g/d) 600 800 800
Iron (mg/d) 16 21 27
Vitamin A (μg/d)
Retinol 600 600 600
β-carotene 4800 4800 4800
Thiamine (mg/d) 0.8 1.1 1.0
Riboflavin (mg/d) 1 1.3 1.2
Niacin (mg/d) 13 15 13
Vitamin B6 (mg/d) 1.6 1.6 1.6
Ascorbic acid
(mg/d)
40 40 40
Dietary folate (μg/d) 120 140 140
Vitamin B12 (μg/d) 0.2-1 0.2-1 0.2-1
Source: ICMR (2010)
DIETARY CONSIDERATIONS
By school age the children establish a particular pattern of food intake. This may
slightly differ from what is followed at home due to peer influence. The child may try new
foods which they normally do not consume. Breakfast is a very important meal. Children
are generally restless and spent very little time at the table. Skipping breakfast affects their
performance level and the calorie and nutrients lost cannot be made up at any other time
during the day. The following points should be considered while planning meals for school
going children:
i. The meal should be nutritionally adequate and balanced. Inclusion of milk, green
leafy vegetables, and fruits are essential.
ii. New foods should be introduced from time to time, so that the school children learn
to enjoy a wide variety.
iii. Since, the child goes to school, he eats one meal away from home, which is a major
change at this stage. It requires considerable planning and management to ensure
that a child is well fed, even when he eats away from home.
iv. A substantial easy to carry and easy to handle snack or lunch will minimize the
temptation for trying foods categorized as providing empty calories.
138
v. The evening meal plan for the child must take into consideration the type of lunch
he has had. At the same time. It should not be of such nature, that it takes away the
appetite for dinner.
vi. Variety in terms of colour, texture and flavour is necessary; the menu of the packed
lunch should be changed frequently.
vii. Customs, religion and tradition of the family should be kept in mind.
viii. Planning of the meals should not exceed the planned food budget. Cheaper, yet
nutritious food stuffs can be selected, if required e.g. parched gains, groundnut,
sprouted grains, green leafy vegetables, etc.
ix. Seasonal vegetables and fruits should be included in the diet.
x. The likes and dislikes of the child should be kept in mind to some extent, but that
does not mean that it should exclude a particular food group, but its forms should
be changed e.g. if milk is not liked, then its original form could be changed by
adding Bournvita, chocolate etc.
xi. The food cooked should not be too spicy or fried, however a small amount of spices
can be allowed at this stage.
xii. The mealtime should be pleasant and relaxing and not a time for discipline.
xiii. Items may be selected according to the socio-economic level of the family. Suitable
substitutions and variations can be made as to the availability and seasonality of
particular vegetables and fruits. Mid-morning snack and lunch can be selected
according to the school timings.
Packed lunch
Packed lunch have become a necessity for school children as it is not possible to have
lunch at home. Packed lunch is a lunch in a tiffin box to be eaten by the child while away
from home. Points to be considered while planning packed lunches are:
▪ It should meet one third of the day’s nutritional requirements.
▪ It should include food from all the five food groups though the number of dishes
may be less.
▪ At least one serving of green leafy vegetables should be included.
▪ Food stuffs providing good quality protein like egg, milk or milk product like paneer
or curd would improve overall protein quality in combination with vegetable protein.
▪ Variety should be present.
▪ Preferably the food packed should be different from that prepared for breakfast.
▪ The dishes should be packed at right consistency so as to avoid leakage or food
becoming dry during lunch which may not be appetising to the child.
139
Table 11.2 illustrates some suggestions for selecting food items for a school going
child of different socio-economic levels.
Table 11.2: Suggested meals items for the school children
Meal Suggested Menus
Breakfast Fermented whole wheat flour chapati with
groundnut chutney.
Daliya and green gram porridge.
French Toast, Milk, orange
Plain Paratha with curd
Paushtik roti with fresh tomato
Chutney, jaggery
Packed Tiffin Paushtik paratha, stuffed paratha;
Chapatti/ missi roti, sabzi
Soyabean/chana dal/paneer pulao;
Cheese Tomato Sandwich;
Wheat besanladoo, cake piece;
Guava, Banana,
Lunch or Dinner Paushtik Khichri, Salad.
Nutrinugget pulao, Curd
Groundnut fried rice, tomato chutney.
Lentil Khichri, Potato Peas Raita
Stuffed Parantha, Carrot strips, Curd.
Tea Chirwa
Upma
Bread/Rusk
Parched grain, jaggery
Sprouted chana
LET’S CHECK THE PROGRESS
1. Discuss the growth and development in school-aged children.
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
2. What are the factors to be kept in mind while planning meals for school-aged children?
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
140
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
3. Suggest five interesting and nutritious packed tiffin menus for school going children.
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
SUMMARY
School age is the phase of slow but steady growth and development on all fronts.
Children begin to develop the feeling of independence and peer influence become evident.
All this effects the food choices and dietary behaviour. Nutrition for the school aged
children should promote growth, and meet energy and nutrient needs without promoting
too much weight gain. During the school years, children will experience increased
opportunities to make choices about their food intakes. Parents can help their children make
positive food choices by planning family mealtimes, keeping a variety of foods in hand and
setting positive examples. Habits formed in childhood are likely to carry into adult years.
KEY WORDS
Peer pressure- influence of peer and schoolmates.
REFERENCES
➢ ICMR. Nutrient requirements and recommended dietary allowances for Indians. A
report of the expert group of the Indian Council of Medical Research, National
Institute of Nutrition, Hyderabad. 2010.
➢ NIN. Dietary Guidelines for Indians- A Manual. Indian Council of Medical Research,
National Institute of Nutrition, Hyderabad, 2011.
➢ Onis MD, Blossner M. WHO global database on child growth and malnutrition.
WHO. 1997. Available from: http://whqlibdoc.who.int/hq/1997/WHO_NUT
_97.4.pdf .
➢ Chadha, R., & Mathur, P. (2015). Nutrition: A Lifecycle Approach. 1st Ed. Orient
BlackSwan
➢ An Advanced Textbook of Nutrition, Vol, II, Dr. M. Swami Nathan.
➢ Fundamentals of food and Nutrition, S.R Mudambi, Rajagopal.
➢ A textbook of Food and Nutrition, Education Planning Group.
➢ Applied Nutrition, R. Rajalakshmi, Oxford and IBH.
141
LESSON 12
NUTRITION DURING ADOLESCENCE
A transitional period between childhood and adulthood, adolescence provides an
opportunity to prepare for a healthy productive and reproductive life, and to prevent the
onset of nutrition-related chronic diseases in adult life, while addressing adolescence-
specific nutrition issues and possibly also correcting some nutritional problems originating
in the past. They are usually open to new ideas; they show curiosity and interest. Many
habits acquired during adolescence will last a lifetime. Furthermore, with increasing age,
adolescents’ personal choices and preferences gain priority over eating habits acquired in
the family, and they have progressively more control over what they eat, when and where.
There is potential for correcting nutritional inadequacies and perhaps even for catch-up
growth during this period.
OBJECTIVES
After going through this lesson you will be able to
❖ Discuss the various physical, physiological and psychological changes during
adolescence during adolescence
❖ Plan meals for these age groups according to their specific nutrient requirements.
❖ Identify the key nutritional problems that affect adolescents
ADOLESCENCE
Adolescence is a period of transition between childhood and adulthood. It is
characterised by rapid growth and development. This covers almost a span of ten years.
Individual variation is also great in this group. A number of physical changes and mental
changes occur in this period of life. Girls mature between 11-14 years of age and boys
between 13-16 years. The pattern of body water, lean body mass, bone and fat
show noticeable differences between boys and girls.
Growth spurt
The second and final growth spurt occurs during this period. The process of
physical development from a child to an adult is called puberty. The growth spurt occurs
in girls at approximately 11-14 years and in boys 13-16 years. Growth in girls in terms
of height and weight is maximum prior to menarche. It is very rare that girls gain height
after menarche, which is hardly 2-3 cm. In boys growth continues till late teens. They
tend to gain weight at a faster rate and by 18-20 years, they have achieved their full
height.
142
Physical, physiological and psychological changes
Body composition
Body composition changes during the period of maturation. The changes occur due to
hormonal influence which regulate the development of sex characteristics. The skeletal
growth continues for a longer period of time for boys than girls. Usually the skeleton
reaches its full maturity by 17 years for girls and by 20 years for boys. As mineralization
increases the water content decreases.
Girls tend to deposit more fat whereas boys add more muscle mass. The result of
pubertal changes is that boys have more lean body mass, skeletal weight and less adipose
tissue as a ratio of total body mass. This difference in body composition for boys and
girls is reflected in their nutrient requirements.
Sexual maturity
The growth spurt is accompanied by sexual maturity. In girls there is development of
breasts, auxiliary and pubic hair and menarche. In boys the pubertal changes include
deepening of voice, broadening of shoulders, development of auxiliary and pubic hair,
growth of penis and testicles.
Psycho social changes
As this period is a transition to adulthood, they try to develop self-identity. The desire to
be accepted in their peer group changes their food habits, dressing and group conduct.
This in turn brings psychological, emotional and social stress.
As may be expected, the nutritional needs during this second very rapid growth
period are tremendous. Anyone who has seen a teenager’s diet during this period will
attest to his voracious appetite. If plenty of foods are available, they will be eaten,
especially by boys. Unfortunately, enough of even a poor choice of foods will also satisfy
the appetite, but will not supply the essential nutrients required for growth. The difference
between poorly nourished and well-nourished becomes evident during this period.
Normally, the poor diet is inadequate in both calories and calcium, but the adolescent boy
may not show any obvious evidence of calcium deficiency because of stunted growth
resulting in decreased calcium requirements. Also, a deficient supply of calcium may
lead to reduction in food intake and stunted growth. Occasionally, a fast growing
adolescent may have an adequate calories supply combined with a deficiency of calcium,
and this results in poor skeletal growth and an uneven gait. Symptoms such as bowed
legs, and flat feet becomes exaggerated during this period.
NUTRITIONAL REQUIREMENTS
Requirements of adolescents are determined on the basis of their sex. Age,
puberty, and growth rate are other factors in determining the nutritional requirements of
adolescents. Indian Council of Medical Research (ICMR) has recommended the amount
of nutrients on the basis of chronological age. Adolescence is divided in two age groups.
143
13-15 years and Requirement of nutrients is proportionate to their growth whereas
requirement of energy is largely determined by their level of activity. Nutrients required
by adolescents are discussed below and the same are tabulated in Table 12.1.
Energy
The metabolic demands of growth and energy expenditure increases the calorie
needs. The ICMR committee has suggested that energy should be provided on the basis
of ideal weight for age. The spurt in growth is earlier for girls and a little later for boys.
Therefore, the energy intake is higher for girls at 13-15 years and for boys at 16-18 years.
Also the difference in energy intake between adolescent girls and boys is partly due to a
lower metabolic rate in females as compared to males. The boys require 2750 Kcal at 13-
15 years, while 3020 Kcal at 16-17 years of age. Adolescent girls require
2330 Kcal at 13-15 years and 2440 at 16-17 years of age.
Protein
The protein requirements are computed in the same way as for adults. The protein
needs represent 12-14 percent of the total energy requirements. This meets the need for
growth, for pubertal changes in both sexes and for developing lean body mass in boys.
Protein intake for boys is significantly higher than girls due to a bigger stature of boys.
At the end of growth period boys have one and a half times more lean mass as compared
to girls. Girls have larger portions of fat deposits. The boys require 54.3 g and 61.5 g of
protein at 13-15 years and 16-17 years of age respectively.
Vitamins
The structural and functional integrity of newly formed cells depends on the
availability of vitamins A, C and E. Requirement for vitamin A is the same as during
childhood i.e. both the sexes require 600 mcg of retinol from 13-17 years of age. Vitamin
C requirement is the same as during childhood i.e. 40 mg. The requirement for B vitamins
namely thiamine, riboflavin and niacin increases in direct proportion with increase in
calorie intake. Folic acid and vitamin B12 requirements also increase when there is rapid
tissue synthesis as they participate in synthesis of DNA and RNA. Thiamine,
riboflavin and niacin requirements are recommended in relation to increased calories
intake. The requirement of these vitamins is always higher for boys due to increased energy
requirement. The requirement of 150- 200 mcg of folic acid has been recommended, taking
in to account the bioavailability of food folates. Since vitamin B12 is present only in animal
foods and Indian diets are basically vegetarian, dietary allowance of 0.2-1.0 mcg has been
recommended, which also takes into account cooking losses and the uncertainty about the
extent of absorption of vitamin B12. Transamination to synthesize non-essential amino
acids requires more vitamin B6. The requirement for vitamin B6 is considered to be related
to protein intake and adolescents require 2.0mg daily.
144
Minerals
Calcium
Bone growth requires calcium. Calcium requirements are based on calcium accretion
during the period of growth. Since the bones grow in size and number and mineralization
continues even after full length is attained, the calcium requirements are higher during
peak of growth and slightly lower thereafter for both boys and girls. Both the sexes
require about 800mg of calcium during adolescence.
Iron
Iron need is higher than during childhood due to continuous increase in the blood volume.
Adolescent boys require about 28-32mg of iron at 13-17 years of age. Girls require 27mg
at 13-15 years and 26 mg at 16-17 years.
Table 12.1: ICMR recommended dietary allowances for Adolescents
Group Boys Girls Boys Girls
Category/Age 13-15 years 13-15 years 16-17 years 16-17 years
Body weight (Kg) 47.6 46.6 55.4 52.1
Energy (kcal/d) 2750 2330 3020 2440
Protein (g/d) 54.3 51.9 61.5 55.5
Visible fat (g/d) 45 40 50 35
Calcium (g/d) 800 800 800 800
Iron (mg/d) 32 27 28 26
Zinc (mg/d) 11 11 12 12
Magnesium (mg/d) 165 210 195 235
Vitamin A (μg/d)
Retinol 600 600 600 600
β-carotene 4800 4800 4800 4800
Thiamine (mg/d) 1.4 1.2 1.5 1.0
Riboflavin (mg/d) 1.6 1.4 1.8 1.2
Niacin equivalent
(mg/d)
16 14 17 14
Vitamin B6 (mg/d) 2.0 2.0 2.0 2.0
Ascorbic acid
(mg/d)
40 40 40 40
Dietary folate (μg/d) 150 150 200 200
Vitamin B12 (μg/d) 0.2-1 0.2-1 0.2-1 0.2-1
Source: ICMR (2010)
NUTRITIONAL CONCERNS
Adolescence is also challenging for nutrition, even if nutritional vulnerability may
not be as great as in infancy and childhood. Adolescents are exposed to undernutrition,
micronutrient malnutrition as well as obesity. Their lifestyle and eating behaviours, along
with underlying psychosocial factors, are particularly important threats to adequate
nutrition. The following are seen as the main nutritional issues of adolescents:
145
Obesity
Obesity among both adolescents and adults is increasing worldwide in both poor and rich
economies. While genetic factors have a role, environmental factors (a sedentary life style
and high fat diets) play the dominant role. The major long term consequence of adolescent
obesity is persistence into adulthood and association with an increased risk of
cardiovascular and metabolic disease in later life. It is estimated that at least one half of
cardiovascular mortality is nutrition-related and up to half of type-2 diabetes cases are
nutrition-related. In addition obesity in adolescent has other undesirable health
consequences.
Micronutrient deficiency
Iron is the most widespread micronutrient deficiency. Deficiency is most prevalent among
pregnant women, followed by pre-school children and adolescents – particularly girls. Key
causes include poor dietary intake, reduced bioavailability and increased losses due to
intestinal worms. Efforts to mitigate iron deficiency should include diets rich in Vitamin C
(to increase bioavailability of iron) and Vitamin A (to increases the effectiveness of iron).
As maximum bone growth occurs during this period adolescents are prone to
calcium deficiency and increased tendency to bone fracture. Later on in life calcium
deficiency in adolescence is associated with high post-menopausal bone loss. These
deficiencies and effects can be reversed by adequate intake of calcium. Studies have also
reported a positive impact of zinc on linear growth among adolescents with zinc deficiency
– particularly boys.
Iodine deficiency is still an issue in parts of the world without access to iodised
salt. To prevent the deleterious mental effects of iodine deficiency on the foetus, normal
iodine status must be achieved prior to pregnancy; and for this to happen adolescents,
particularly girls, should be targeted in places where iodine deficiency is endemic.
Although Vitamin A deficiency has in the past been seen as primarily a problem
of children under the age of five years, it is now recognised from the impact of
supplementation studies that it may be widespread among women, and an important
contributor to maternal mortality. It may also be common among adolescent girls; and as
indicated above, it is entangled with iron deficiency. Therefore adolescence is a good time
to prevent vitamin A deficiency. This can be achieved primarily through education and
food.
146
Figure 12.1: A conceptual framework of nutritional problems and causal factors in
adolescence
Unhealthy eating habits
The dietary patterns observed among adolescents which put them at risk of unhealthy eating
include snacking (on energy-dense but nutrient-poor items); meal skipping; irregular eating
patterns; and a wide use of fast food for meals and snacks. Healthy snacks can be important
for adolescents owing to their high energy requirements but fast foods - a popular choice –
can contribute to high intakes of saturated fat. Other common habits include eating away
from home, low intake of fruits, vegetables and dairy products. Self-image and body weight
concerns particularly in girls may lead to faulty dieting practices. Tooth decay and
periodontal disease may result from a combination of poor oral hygiene and poor eating
habits. Because adolescence is characterised by increasing maturity and a trend towards
autonomy and independence, adolescents are generally curious, adaptive and open to new
ideas. They may explore unconventional dietary practices (e.g. vegetarian diets). As they
mature, their own choices and preferences gain priority over eating habits acquired in the
family and they have more control over what they eat, when and where. This is an important
window for nutritional education interventions with potential to impact lifetime eating
habits and health.
Anaemia
There is an increasing trend towards a decrease in age of menarche both in upper affluent
class and rural communities making adolescent girls susceptible to anaemia because of
147
smaller stores of iron and the onset of menstruation imposes additional requirement of Iron
to compensate for menstrual blood loss. In Indian girls, the highest prevalence of anaemia
is reported between the ages of 12-13 years which also coincides with the average age of
menarche. In girls, the lower total food intake or energy intake by compared to boys,
combined with menstrual losses cause adolescent girls to be at greater risk of Iron
deficiency anaemia.
Figure 12.2: Intergenerational cycle of anaemia
Early pregnancy
Adolescent pregnancies are a global problem occurring in high-, middle-, and low-income
countries. Around the world, however, adolescent pregnancies are more likely to occur in
marginalized communities, commonly driven by poverty and lack of education and
employment opportunities. Early pregnancies among adolescents have major health
consequences for adolescent mothers and their babies contributing to maternal mortality,
morbidity and lasting health problems. Early childbearing can increase risks for new-borns
as well as young mothers. Social consequences for unmarried pregnant adolescents may
include stigma, rejection or violence by partners, parents and peers.
Eating disorders
Eating disorders are diseases that cause severe malnutrition, including extreme thinness, as
a result of abnormal eating behaviours such as binge-eating, and self-vomiting and they
stem from an intense fear of obesity. Eating disorders are not a function of will but are,
rather, unhealthy eating patterns that “take on a life of their own.”
Binge eating
Binge eating is an eating disorder characterized by the consumption of a large amount of
food in a small amount of time and may start at any age often not recognized till adulthood.
The individual suffering from this is either overweight or obese and suffer from consequent
148
disorders like high blood pressure, hypercholesterolemia and type II diabetes. Both
psychological and nutritional counselling is extremely important for binge eaters.
Anorexia nervosa
Anorexia nervosa is an eating disorder characterized by refusal to eat and loss of body
weight. This is more common among adolescent girls when they try to avoid eating food
due to over consciousness of their figure and social stress.
Bulimia nervosa
Bulimia nervosa is a serious, potentially life-threatening eating disorder characterized by a
cycle of bingeing and compensatory behaviours such as self-induced vomiting designed to
undo or compensate for the effects of binge eating.
Eating disorders may result in fatal consequences due to nutritional deficiencies. it should
be stressed that the disease not only causes disorders in eating behaviours, but it also
diversely affects the physical, psychological, and social aspects of the patient. Eating
disorders should be acknowledged as a serious disease that is difficult to treat. Figure 12.3
gives the vicious cycle of eating disorders.
Figure 12.3: Vicious Cycle of Eating Disorders
DIETARY CONSIDERATIONS
While planning meals for adolescents it is important to consider whether the adolescent
is in the age group of 13-15 years or 16-18 years along with other factors like sufficiency
in nutrition, acceptability and availability of food, etc. It is also necessary to know whether
the adolescent is a boy or a girl, what is his routine, and to which income group he belongs.
The following points should be kept in mind:
i. The planned diet should be well balanced. With the increase in calcium
requirement, extra milk can be provided, if possible. For an adolescent, from low
SES, cheaper calcium rich sources should be provided like parched grains, whole
Restricting
Binging
Purging
Shame/Sense of loss of control
Overvaluation of thinnes/control
149
grain cereals and pulses and green leafy vegetables. The diet should also contain
sufficient energy sources to meet the increased energy requirements. Girls tend to
be anaemic as their iron requirement increases considerably. This increased iron
requirement should be taken care of by providing green leafy vegetables, whole
grain cereals and pulses, and if possible, egg, meat, liver and fish.
ii. Likes and dislikes should be considered.
iii. Socio Economic status (SES) of the family should be kept in mind. An adolescent
from low SES may want to copy his classmates from high SES with respect to the
purchase of high cost snacks. To avoid that, they should be given cheap yet
attractive and nutritious snacks in tiffin.
iv. There should be variety in terms of colour, texture and flavour. The adolescents are
more fussy, especially girls about eating at home. Meals served if attractive, will
encourage them to eat at home.
v. If tiffin is to be given, it should be nutritionally balanced, more so if it is in place
of a main meal.
vi. Seasonal drinks like milk shakes, cold drinks and tea/coffee may be included to
make the day’s diet interesting.
vii. Satiety value of the diet should be taken care of, especially for the boys. If they are
still hungry, extra salad can be provided.
viii. The meals should be served in a pleasant atmosphere.
ix. ‘Snacking’ in between meals is common amongst adolescents. Snacks should be
wholesome and not only a source of energy but also proteins and other essential
nutrients.
SAMPLE DIET PLAN
A day’s sample Menu for a 16 year old adolescent girl
Recommended Dietary Allowance
Energy: 2440 Kcal Calcium: 800mg
Protein: 55.5g Iron: 26 mg
Meal Menu Food Stuffs Amount (g)
Breakfast Mango shake Milk 200
Mango 100
Sugar 10
Toasted Bread Bread 60
Butter 15
Sprouted Chana Chana 30
150
Tomato 25
Lemon 10
Packed Lunch Paushtik Parantha Wheat Flour 60
Chana Flour 20
Ghee 15
Potato, Spinach Potato 70
Vegetable Spinach 100
Onion 25
Oil 10
Apple Apple 75
Tea Cold Coffee Milk 125
Sugar 10
Besan Laddoo Besan 20
Ghee 10
Sugar 20
Chirwa Rice flakes 30
Peanuts 20
Oil 5
Dinner Boiled Rice Rice 80
Rajmah Rajmah 30
Onion 25
Tomato 25
Oil 10
Plain curd Curd 75
Salad Cucumber 50
Tomato 50
LET’S CHECK THE PROGRESS
1. Discuss any three nutrients that are of significance during adolescence.
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
2. What are the factors you would consider while planning diet for adolescents?
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
151
3. Suggest three nutritious breakfast menus for a vegetarian low income group
adolescent.
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
SUMMARY
Adolescence is a period of transition between childhood and adulthood. It is
characterised by rapid growth and development. Healthy dietary habits should be
developed to meet nutritional requirements. Energy and nutrient dense foods not only
support growth, but also help prevent nutrient deficiencies. This period is associated with
a number of important nutritional issues. At the same time this period provides an important
window of opportunity for interventions that promote the principles of a healthy eating life
style - with potential to radically change the chronic disease landscape among adults across
the world.
KEY WORDS
Peer pressure- influence of peer and schoolmates.
Growth spurt- an occurrence of growing quickly and suddenly in a short period of time
REFERENCES
➢ ICMR. Nutrient requirements and recommended dietary allowances for Indians. A
report of the expert group of the Indian Council of Medical Research, National
Institute of Nutrition, Hyderabad. 2010.
➢ NIN. Dietary Guidelines for Indians- A Manual. Indian Council of Medical Research,
National Institute of Nutrition, Hyderabad, 2011.
➢ Chadha, R., & Mathur, P. (2015). Nutrition: A Lifecycle Approach. 1st Ed. Orient
BlackSwan
➢ An Advanced Textbook of Nutrition, Vol, II, Dr. M. Swami Nathan.
➢ Fundamentals of food and Nutrition, S.R Mudambi, Rajagopal.
➢ A textbook of Food and Nutrition, Education Planning Group.
➢ Applied Nutrition, R. Rajalakshmi, Oxford and IBH.