Jeff Cadge/the Image Bank/Getty Images

(Jeff Cadge/The Image Bank/Getty Images)
CHAPTER 13 CONCEPTS u s t A Ta s t e
J
■ Eating patterns can affect health and nutrition throughout life.
■ Children’s nutrient intakes must meet their needs for growth and
development as well as for maintenance and activity.
■ Normal growth is the best indicator of adequate intake.
■ Sexual maturation affects nutrient needs. Does a child’s diet affect their risk
■ Eating disorders and the use of fad diets, sports supplements, of heart disease as an adult?
and alcohol use all increase during adolescence.
■ Americans are living longer than ever before; good nutrition can
Can fast food and sweetened cereals
help to increase the number of healthy years. be part of a healthy diet?
■ The physiological, social, and economic changes that occur with Can a healthy diet keep you young?
aging increase the risk of malnutrition.
■ Older adults need to consume nutrient-dense diets to meet nutrient Does getting older increase your risk
needs without exceeding their calorie needs. of malnutrition?
■ Alcohol consumption can affect nutritional status, judgment,
and health.
Nutrition from 13
2 to 102
Good Nutrition Early On Is Key
to Health Throughout Life
INTRODUCTION
Healthy Eating Habits Keep Children Healthy
Healthy Eating Habits Are Learned The Orlando Sentinel
Nourishing Young Children Can
Be a Challenge See How They Run Ocoee
Children’s Energy and Nutrient Needs Increase
with Age Elementary. . . .
A Balanced Varied Diet Will Meet Children’s
Nutrient Needs By Kate Santich
Normal Growth Is the Best Indicator
of Adequate Intake
April 12, 2004 . . . At a time when childhood obesity is a
Diet and Lifestyle Affect Nutritional Risks in Children national crisis, when kids are casualties in an epidemic of
type 2 diabetes and high blood pressure, tiny Ocoee
Adolescents Have Changing Bodies
and High Nutrient Needs Elementary School has become a microcosm of hope.
Hormones Cause Sexual Maturation and Changes Professionals from the Health Central Foundation have
in Body Size and Composition teamed with teachers and administrators to spread the
Total Energy and Nutrient Needs Are Greatest gospel of healthy living—regular exercise, good eating
during Adolescence habits, taking care of yourself. . . .
Teens Must Learn to Make Healthy Choices
to Meet Nutrient Needs In January, the entire elementary school—nearly 600
Concerns about Appearance and Performance Can students, kindergarten through fifth grade—launched a
Precipitate Nutritional Problems “wellness challenge.” They walk or run at least once a week,
Good Nutrition Can Keep in addition to other exercise. In the classroom, they learn
Adults Healthy about the food pyramid and the importance of eating fruits
Aging Begins at Birth and vegetables. On the school’s morning announcements,
Aging Affects Recommendations for Some Nutrients guest speakers talk about drinking water instead of soda and
The Physical, Mental, and Social Changes of Aging
Increase Nutritional Risks sum up the latest health findings on children.
The DETERMINE Checklist Helps Assess the Risk No one is chastised for being out of shape. The word
of Malnutrition “diet” is never uttered. The idea is to inspire, not ridicule.
Meeting Nutritional Needs Involves Nutritional, Social,
and Economic Considerations And parents are encouraged to join in as well.
Drinking Alcohol Can Be a Risk To read the entire article, go to www.orlandosentinel.com/.
at All Stages of Life
Alcohol Enters the Bloodstream Quickly
Long-Term Excessive Alcohol Consumption Has Serious
Health Consequences
There Are Benefits to Moderate Alcohol Consumption
If You Drink Alcohol Do So in Moderation
hy does it matter if you eat doughnuts for
W
breakfast and french fries for lunch when
you’re 8 years old? It doesn’t, if you do it oc-
casionally, but a diet based on foods like
these that are high in calories and low in nu-
trients can affect your growth and increase your risk of de-
veloping obesity, heart disease, or diabetes as a child and
later on in life. Unfortunately most 8-year-olds, and other
children and adolescents in the United States today, are eat-
ing doughnuts for breakfast, french fries for lunch, burgers
and shakes for dinner, and sodas and chips for snacks a lot
more often than is healthy.
441
442 Chapter 13 Nutrition from 2 to 102
Good Nutrition Early On Is Key

to Health Throughout Life
A healthy diet is important throughout life. As an infant, the nutrients in formula or
breast milk allow for optimal brain development. As a young child, consuming the
right balance of nutrients is key to optimal growth and development. In the teen
years, good nutrition allows for continued growth, maturation, and sexual develop-
ment. As an adult, a diet that provides enough of the right mix of nutrients can help
postpone or avoid the chronic diseases that are common in the developed world. And
in older adults, a nutritious diet can help maintain health despite diminishing func-
tion in organ systems.
A poor diet at any time in life can affect your immediate and future health. We all
know that undernourished children do not grow well and get sick more often and that
malnutrition during childhood has long-term effects on growth and development.
But, we don’t always think about the fact that dietary excesses during childhood and
adolescence can also affect health throughout life. Therefore, learning to eat a healthy
diet early in life can be one of the most significant factors affecting lifelong health.
Healthy eating habits keep children healthy

We used to think of diabetes, high blood pressure, high cholesterol, and obesity as
adult problems. Not any more. These conditions are occurring more and more often
in children and teens. The reason is believed to be due to changes in the dietary and
exercise patterns of America’s youth. The high-calorie, high-salt, high-saturated fat
diet and low-activity lifestyle that contributes to chronic disease in adults is having the
same effect in children. Fortunately, as with adults, a healthy diet and active lifestyle
can prevent or delay the onset of many of these conditions.
FIGURE 13.1
Overweight teens may become socially isolated,
Overweight and obesity are major problems for U.S.
which reduces physical activity. (Robert E. children It is estimated that more than 15% of U.S. children and adolescents ages
Daemmrich/Stone/Getty Images) 6 through 19 are at risk for becoming overweight.1 As with adults, children who carry
excess body fat are at increased risk of developing chronic diseases. Obese children
may have high blood cholesterol and glucose levels and elevated blood pressure, all of
* Remember
Obesity is due to a combination of genetic
which increase their chances of developing heart disease, diabetes, and hypertension.
In addition to the health issues, obese children in the United States have social and
and environmental factors. Obese parents psychological challenges. They are less well accepted by their peers than normal-
are more likely to have obese offspring not weight children and are frequently ridiculed and teased. They often have a poor self-
only because they pass on their genetic image and low self-esteem, particularly during the teenage years. Obese adolescents
tendencies but also because their children may be discriminated against by adults as well as by their peers. This can lead to feel-
may learn eating and exercise habits that ings of rejection, social isolation, and low self-esteem. The isolation of obese adoles-
lead to weight gain. If sound nutrition and cents from teen society results in boredom, depression, inactivity, and withdrawal—all
exercise habits are developed early and are of which can cause an increase in eating and a decrease in energy output, worsening
followed throughout life, obesity can be the problem (Figure 13.1).
avoided despite a genetic predisposition.
See Chapter 7. Type 2 diabetes is no longer just an adult disease Until re-
cently, type 2 diabetes was considered a disease that primarily affected adults over 40
years of age, but it is now on the rise among America’s youth.2 Little is known about
this disease in children, but based on experience with adults, it is thought to be a pro-
gressive disease that increases in severity with time from diagnosis. It occurs most
often in overweight children with a family history of the disease. The longer an indi-
vidual has diabetes, the greater the risk of complications that involve the circulatory
system or nervous system and that can lead to blindness, kidney failure, heart disease,
or amputations (see Chapter 4).3
Many children and teens have elevated blood choles-

terol The recommended level for blood cholesterol in children 2 through 18 years
is less than 170 mg per 100 ml. In the United States, many children have blood
Good Nutrition Early On Is Key to Health Throughout Life 443
cholesterol levels higher than this. Elevated blood cholesterol levels during child-
hood and adolescence are associated with higher blood cholesterol and higher mor-
tality rates from cardiovascular disease in adulthood. The American Academy of
Pediatrics recommends blood cholesterol monitoring for high-risk children and
teenagers. This includes those with parents or grandparents who developed heart
disease before age 55, and those whose parents have cholesterol levels over 240 mg
per 100 ml. A child who eats a poor diet has
an increased risk of developing
Higher blood pressure in childhood leads to hyperten- elevated blood cholesterol, blood
sion later Children who have blood pressure at the high end of normal are
sugar, and blood pressure levels,
more likely to develop high blood pressure as adults. High blood pressure increases
the risk of stroke, heart disease, and kidney disease. As with adults, blood pressure
all of which increase the risk
can be affected by the amount of body fat, activity level, and sodium intake, as well of developing heart disease in
as by the total pattern of dietary intake. So, even in childhood, a diet that meets but adulthood. On the other hand,
doesn’t exceed nutrient recommendations and includes plenty of exercise can help a healthy diet in childhood can
prevent hypertension. This is particularly important if there is a family history of delay or prevent the onset of
hypertension. heart disease.
Healthy eating habits are learned

Much of what we eat depends on what we have learned to eat. This is not to say that
personal preferences don’t affect intake, but the foods that we learn to eat from our
parents and caregivers as well as our culture have a significant impact on the foods we
choose to eat. If a child’s role models eat a diet high in fat and low in fruits and veg-
etables, the child will likely follow suit. Offering children a variety of healthy, nutri-
tious foods allows them to meet their nutrient needs for growth and development
and to prevent or delay the onset of the chronic diseases that plague American adults.
Unfortunately most children and adolescents in the United States today consume a
dietary pattern that is low in fruits and vegetables and high in sweet and salty
processed foods. They eat more than the recommended amount of fat and not
enough calcium. As children get older, the quality of their diet gets worse; they drink
less milk and eat less fruit (Figure 13.2). These eating habits developed during child-
hood and adolescence may last a lifetime and affect how healthy and how long your
later years are.
100
90
80
Poor diet
70
60
Percent Needs
of improvement
50
children
in the
United 40
States
30 Good diet FIGURE 13.2
20 This graph shows us the percentage of U.S. children between the ages of 2 and 18 who
have a good diet, a diet that needs improvement, and a poor diet. The classification is
10 based on the Healthy Eating Index. A Healthy Eating Index score of 80 out of 100 is
considered a good diet, a score between 51 and 80 is classified as a diet that needs
0 improvement, and a score less than 51 indicates a poor diet. As children grow older, the
2–5 6–12 13–18 percentage that eats a good diet decreases. (U.S. Department of Agriculture, Center of
Age (years) Nutrition Policy and Promotion. Continuing Survey of Food Intakes by Individuals, 1996)
Nourishing Young Children Can Be a Challenge
Nourishing a growing child is not always an easy task. The diet must supply the nutrients
needed for growth and development as well as for maintenance and activity. It must be
appropriate for their stage of physical development and it must suit their developing
tastes. Many factors other than nutrient needs determine which foods a child consumes.
Children’s energy and nutrient needs increase

with age
Children’s nutrient needs increase with age. As they grow and become more active,
their calorie and nutrient requirements grow with them. For example, the average
2-year-old needs about 1000 Calories and 13 grams of protein per day. By age 6, that
child will need about 1700 Calories and 19 grams of protein per day (Figure 13.3).4
The need for most vitamins and minerals also increases as children grow.
Nutrient recommendations are not different for boys and girls until about 9 years
of age, at which time sexual maturation causes differences in nutrient needs between
the sexes. The DRI makes nutrient recommendations for two age groups for children:
toddlers (ages 1 through 3) and early childhood (ages 4 through 8). Children 9 years
of age and older are included in the adolescent group.
After the age of 1 year, fat needs decrease Infants need a high-
fat diet (40 to 55% of energy intake) to support their rapid growth and development,
but as they grow, the recommended proportion of calories from fat is reduced to pro-
vide adequate energy without increasing the risk of developing chronic disease (Figure
13.4). The acceptable range for fat intake is 30 to 40% of energy for children ages 1 to
3 years and 25 to 35% of energy for those 4 through 18 years of age compared to 20
to 35% for adults.4 To reduce the risk of developing high blood cholesterol levels and,
subsequently, heart disease, the diets of children over the age of 3 should contain no
more than 35% of calories from fat and be low in cholesterol, saturated fat, and trans
fat.4 Currently about 70% of children in the United States consume more than the
recommended amount of fat and saturated fat.5 This can lead to elevated blood cho-
lesterol levels. Low-fat diets have been found to promote healthy blood lipid levels
without interfering with growth.6
The proportion of energy from carbohydrate recommended for children over age 2
is the same as that for adults: 45 to 65% of energy. As in the adult diet, most of the
3000 Key
Males
Females
2000
Energy needs
(Cal/day)
1000
0
60
50
Protein needs 40
(g/day)
30
20
FIGURE 13.3 10
0
The need for both energy and protein 2 6 16
increases with age. Age (years)
Nourishing Young Children Can Be a Challenge 445
FIGURE 13.4
Choose a diet that is low in
saturated fat and cholesterol The Dietary Guidelines recommend that everyone over the
and moderate in total fat age of 2 years consume a diet that is low in saturated fat
and cholesterol and moderate in fat. (USDA, DHHS, 2000)
carbohydrate in a child’s diet should be from whole grains, fruits, and vegetables.
These will help to provide the recommended amount of fiber. Fiber supplements are
not recommended for children because high intakes can fill them up, limiting the
amount of food and, consequently, the nutrients that a small child can consume.
Foods high in added sugars, such as cookies, candy, and soda, should be limited.
Most children consume enough fluids but too much salt
By 1 year of age, a child’s kidneys have matured and the water lost through evapora-
tion has decreased, so fluid losses decline. As with adults, under most situations,
drinking enough to satisfy thirst will provide sufficient water. In children 1 to 3 years
of age about 1.3 liters (5 1/2 cups) of fluid daily will meet needs; about 4 cups of this
should be from water and other fluids and the rest from food. Older children, ages 4
to 8, need about 1.7 liters (7 cups) of fluid per day.7 These needs increase when the
environmental temperature is high or activity increases sweat losses.
The typical sodium intake in children and teens currently exceeds the recom-
mended amount. A UL of 2.3 grams of sodium per day has been set for adults and
A low vitamin D intake may be
teens 14 to 18 years of age, because a high sodium intake is associated with elevated
putting children’s bones at risk.
blood pressure. The UL is somewhat lower in children and younger teens.7
Recently, rickets due to vitamin D
Adequate calcium is essential for maximizing peak bone deficiency has been appearing
mass Adequate calcium intake during childhood is essential in order to develop among urban children who have
strong, dense bones; the greater the bone density, the lower the risk of developing os- dark skin, get little sun exposure,
teoporosis later in life (see Chapter 9). The AI for calcium for toddlers is 500 mg per and consume vegetarian diets.
day and for young children is 800 mg per day. Despite the importance of calcium for When sun exposure is limited,
maximizing peak bone mass, calcium intake in school-age American children is de- dietary vitamin D becomes more
clining, primarily due to a decrease in the consumption of dairy products, such as important in meeting needs.
milk, yogurt, and cheese. Only 79% of girls and 89% of boys ages 2 to 8 consume the
recommended amount of calcium.8 (See Your Choice: No Bones About It?) For more information on
calcium and health go
Iron deficiency is common in children Iron deficiency anemia is to the Milk Matters
one of the most prevalent forms of malnutrition in children. Although iron intake by Web site of the National
American children has increased over the last 20 years, iron deficiency is still a public Institute of Child Health
health problem.9 Iron deficiency anemia can lower a child’s resistance to illness and and Human Development at
slow recovery time. It can affect learning ability, intellectual performance, stamina, www.nichd.nih.gov/milk/milk.cfm
and mood. Good sources of iron that are acceptable to small children include fortified
grains and breakfast cereals, raisins, eggs, and lean meats. If anemia is diagnosed, iron
supplements are usually prescribed until iron stores are replenished. These supple-
ments should be kept out of the reach of children. Overdoses of iron-containing sup-
plements are the leading cause of poisoning deaths among children under 6 years of
age.10 To help protect children, products containing iron include a warning about the
hazards to children of ingesting large amounts of iron. Products containing 30 mg or
more per dose are packed in individual doses to reduce the chances of consuming
enough to cause toxicity.
Your Choice: No Bones About It?
Are you thirsty? How about an ice-cold cola? It shouldn’t

be hard to find one. Soft drink-stocked vending machines
can be found in our schools, on college campuses, at
museums, and just about everywhere else. The refrigerator Vitamins
Nutrition Facts
Serving Size 1/4
cup (15g)
Serving Per Container
Amount Per Serving

Calories 60
About 30
A&D
1g
Total Fat
section of convenience stores is filled with bottles and cans

0mg
Sodium 50mg
Potassium 1mg
added
Total Carbohydrate 1g
Fiber 0g
Sugars 2g
Protein
Infants Children
0-1 1-4
% Daily Value 6%
of these carbonated concoctions and they take up an entire

7%
Protein 0% 0%
Vitamin A 0% 0%
Vitamin C
Low-fa
15% 10%
Calcium 45% 60%
Iron 15% 8%
Vitamin E
t
45% 30%
Thiamin 45% 30%
Riboflavin 25% 20%
Niacin 15% 10%
aisle in the supermarket. They have become a part of

MILK
Phosphorus
American culture—we think of them as a thirst quencher, a

snack, and a beverage to gulp along with our meals—but
what are they providing nutritionally? Other than water
their most striking contribution is about 10 teaspoons of
sugar per 12-ounce can. You wouldn’t eat a candy bar with
every meal, yet you probably don’t think twice about the
Lowfat Cola
sugar in your beverages. milk soft drink
Soft drink consumption is a concern at any age, but it
Serving size (oz) 8 12
is a particular concern for children and teens. An average Energy (Cal) 102 150
teenage boy consumes about 19 ounces of nondiet soda a Protein (g) 8 0
day, and teenage girls consume about 12 ounces. This adds Calcium (mg) 300 0
Phosphorus (mg) 235 45
15 teaspoons of sugar to a boy’s diet and about 10 Riboflavin (mg) 0.4 0
teaspoons to a girl’s diet, providing almost 10% of their Vitamin A (µg) 144 0
daily calories.1 Since these averages include teens who drink Vitamin D (µg) 2.5 0
Caffeine (mg) 0 40
no soda, the numbers are even higher for many boys and
girls. This might not be too bad if the soda were replacing
other low-nutrient-density foods like cookies or cakes, but
The number of bone fractures among children and young
as teens have increased their consumption of soft drinks,
adults has increased; this is hypothesized to be due to low
they have decreased their milk consumption. Teenage boys
calcium intakes.2 Even girls who drink diet sodas do not
and girls today drink twice as much soda as milk, whereas 20
spend their extra calories on milk. They may replace milk
years ago boys drank more than twice as much milk as soda
with diet soda to cut calories and lose weight but by doing
and girls 50% more milk than soda.1
so they are also cutting themselves short on calcium.
What does replacing milk with soda do to the overall
Osteoporosis is a major problem among older adults today,
diet? Replacing an 8-ounce glass of milk with a 12-ounce
but when these adults were children they drank twice as
soda increases calorie intake and reduces the intake of
much milk as today’s children. Make no bones about it,
protein, calcium, vitamin A, vitamin D, riboflavin, and other
calcium is important and by substituting soda for milk,
nutrients provided by milk (see figure). Since most soft
children and teens are putting their bones at risk.
drinks today come in 20-ounce bottles rather than 12-ounce
cans the number of added calories is even higher. Milk is the
References
major source of calcium in the American diet, so calcium is 1. Jacobson, M. F. Center for Science in the Public Interest. Liquid candy. How soft
the nutrient of greatest concern. Only 36% of boys and 14% drinks are harming Americans’ health. Available online at www.cspinet.org/
of girls consume the recommended amount of calcium, and sodapop/liquid_candy.htm. Accessed September 2, 2004.
2. NIH, NICHD. Calcium crisis affects American youth. December 10, 2001.
insufficient calcium intake increases the risk of osteoporosis Available online at www.nichd.nih.gov/new/releases_bak_20040224/
and may even be increasing the fracture rate in children. calcium_crisis.cfm. Accessed September 2, 2004.
PIECE IT TOGETHER
Too Many Calories, Too Little Iron

Alex is 8 years old and has a history of iron deficiency anemia. vegetables and whole grains means his fiber intake is low,
His parents are worried because he is gaining weight and all he and some vitamins and minerals may be deficient in the
wants to do is lie around and watch TV. He used to play active, diet. The candy and chips add energy, fat, sugar, and/or
imaginative games with his toys and enjoy basketball with his salt with few other nutrients.
friends. Since Alex’s parents are both overweight, they are
concerned that he will also have a weight problem, so they W HYMIGHT EXCESSIVE CONSUMPTION OF DAIRY
take him to the pediatrician. PRODUCTS CONTRIBUTE TO A LEX ’ S ANEMIA ?
▼
The nurse weighs and measures Alex and draws a blood
sample to check for iron deficiency anemia. She compares Dairy products are an important source of protein, vitamins,
Alex’s weight for height to last year’s measurements. Last and minerals, particularly calcium, but they are a poor
year he was at the 50th percentile, and he is now almost at source of iron. In addition, the high calcium they provide
the 75th percentile. decreases absorption of iron consumed at the same meal.
The pediatrician reports that Alex is anemic again and S UGGEST SOME DIETARY CHANGES THAT WOULD
prescribes an iron supplement. She also refers Alex and his INCREASE A LEX ’ S IRON INTAKE AND ABSORPTION .
parents to a dietitian for counseling on iron intake and
weight management. The dietitian reviews Alex’s diet and ▼
exercise patterns. She learns that he has been watching TV Your answer:
or playing video games for about 6 hours a day. Below are
the responses she gets when she asks Alex about how often
he consumes certain foods:
H OW CAN A LEX REDUCE THE
Servings/ Servings/ ENERGY CONTENT OF HIS DIET ?
Food Day Week ▼
Milk and
dairy products: Whole milk 6 Because Alex is well past the age when he needs a high-fat
Meat and eggs: Red meat 1 diet for growth and development and his weight is increasing
Chicken 2 more rapidly than his height, the dietitian recommends that
Fish 1 he switch to low-fat milk and dairy products. The dietitian
Eggs also suggests that the family make some changes in the
Grains and Whole grains 2 types of food they have around the house so Alex can have
cereals: Refined grains 4 nutrient-dense choices such as fruits and vegetables to replace
Fruit and juices: Citrus 1 the candy and chips he currently snacks on. The dietitian
Other 2 encourages the family to bake, broil, or grill their meat,
Vegetables: Dark green leafy trimming off excess fat. She also recommends the family
Other 1 work together to increase the amount of exercise they get.
Added fats: 3
TO HELP A LEX INCREASE HIS ACTIVITY LEVEL SUGGEST
Snack foods: Chips, etc. 1
SOME ACTIVITIES AN 8- YEAR - OLD BOY MIGHT ENJOY.
Candy 1
▼
W HAT NUTRIENTS ARE LIKELY TO BE EXCESSIVE Your answer:
OR DEFICIENT IN THIS DIETARY PATTERN ?
▼
Alex’s high intake of regular dairy products provides a good
source of calcium but adds a lot of fat and saturated fat to
his diet. His low intake of meats and leafy green vegetables
means his iron intake is probably low. His low intake of
A balanced varied diet will meet children’s

nutrient needs
Because they have small stomachs, children need frequent meals and snacks to assure
an adequate nutrient intake. Breakfast is particularly important in meeting children’s
nutrient needs because it provides the first energy and nutrients of the day. (See Your
Choice: Breakfast Is Brain Food.) Snacks should be as nutritious as meals. Children’s
diets, like those of adults, should include plenty of whole grains, vegetables, and fruits
and be adequate in milk and other high-protein foods. Fat and sodium intake should
be moderate and intake of saturated fat, trans fat, and added sugars should be limited.
A healthy diet can be planned using the recommendations of the Food Guide Pyra-
mid, choosing the low end of the suggested range of servings, and modifying portion
sizes. For instance, an adult serving of milk would be 1 cup, whereas a serving for a
2-year-old would be 4 ounces and for a 5-year-old it would be 6 ounces (Table 13.1).
A Food Guide Pyramid, designed to be appealing to young children, has been devel-
oped (Figure 13.5).
Creativity helps encourage young children to consume a

varied diet Although children determine what they will actually eat, caregivers
are responsible for deciding what foods should be offered, when they should be of-
fered, and where they should be consumed. Substituting appropriate nutritious
choices for refused foods can increase the variety of the diet. Vegetables can be added
TABLE 13.1
A Typical Day’s Food Intake for 3- and 8-Year-Old Children
Amount
Food 3-yr-old 8-yr-old
Breakfast
Corn flakes 3 Tbsp 3/4 cup
Milk, 2% 1/2 cup 3/4 cup
Banana 3 Tbsp half
Snack
Peanut butter 1 Tbsp
Wheat crackers 3
Apple juice 1/2 cup
Lunch
Vegetable soup 1/4 cup 1 cup
Grilled tuna sandwich half 1
Tomato 1/4 1/2
Snack
Hot cocoa 1/2 cup 3/4 cup
Peanut butter and jelly sandwich 1
Cookie 1 2
Snack
Pretzels 2 4
Orange juice 1/2 cup 1/2 cup
Dinner
Rice 3 Tbsp 3/4 cup
Chicken 1 drumstick 2 drumsticks
Broccoli 1 floret 3 florets
Ice cream 1/2 cup 3/4 cup
FIGURE 13.5
This version of the Food Guide Pyramid is designed to be appealing for children 2 to 6 years of age. (USDA, 1999)
449
Your Choice: Breakfast

Is Brain Food
Do you eat breakfast? If not, you probably should. It feeds vitamin B12, pantothenic acid, and iron. When 1/2 cup of
your body and fuels your brain. When you haven’t eaten reduced-fat milk is added to the cereal, it also provides 15%
since the night before, your brain and other tissues have to of the Daily Value for calcium. Children who eat ready-to-
rely on nutrients released from your body stores. But after eat cereals, sugared or not, have a higher overall intake of
you’ve eaten breakfast, you have a ready supply of glucose vitamins and minerals than children who do not eat cereal.3
and other nutrients to get you going. Research studies have Children who cannot or will not eat breakfast before
found that those who eat breakfast perform better on they leave the house can take a snack to be eaten on the
achievement tests and have fewer behavior problems in way to school or during recess. Fruit, yogurt, a bag of dry
school.1 Breakfast eaters are also more likely to meet their cereal, or half a sandwich is certainly a better alternative
nutritional needs than breakfast skippers.2 Many children than no breakfast at all. Having breakfast at school is also
and teens are not particularly hungry first thing in the an option. The National School Breakfast Program is
morning and will gladly go off with an empty stomach. available in about half the nation’s schools and serves more
Whether the child is in preschool or high school, this may than 7 million children. For families who meet income
be detrimental to both school performance and total guidelines the meals are free or offered at a reduced cost.
nutrient intake.3 Children participating in the National School Breakfast
So, what should you have for breakfast? A good Program have higher achievement test scores than eligible
breakfast should provide a quarter to a third of the day’s nonparticipants.1 The breakfasts served must provide at
nutrient needs. For example, a bowl of oatmeal with milk least 25% of the 1989 RDA for certain nutrients and furnish
and raisins, and a glass of orange juice provides about 300 at least 1 serving of milk; 1 serving of fruit, juice, or
Calories as well as B vitamins; vitamins C, A, and D; and vegetables; and either 2 servings of bread, 2 servings of
calcium and iron. Though not every child will eat this good meat, or 1 serving of each. This is probably a good guideline
breakfast, even children who do not like breakfast may be for the breakfast you serve at home as well.
willing to consume a slice of toast with peanut butter or a
bowl of interestingly shaped colored cereal. Although a References
1. Kennedy, E., and David, C. USDA School Breakfast Program. Am. J. Clin. Nutr.
bowl of oatmeal is preferable to a breakfast of Cookie Crisp, 67:798S–803S, 1998.
even the most sugary cereal has some redeeming features. 2. Nahikian-Nelms, M. Influential factors of caregivers’ behaviors at mealtime:
For example, while 40% of the energy in Cap’n Crunch is A study of 24 child care providers. J. Am. Diet. Assoc. 97:505–509, 1997.
3. Nicklas, T. A., O’Neil, C. E., and Berenson, G. S. Nutrient contribution of
from simple sugars, it provides 20% or more of the Daily breakfast, secular trends, and the role of ready-to-eat cereals: A review of the
Value for thiamin, riboflavin, niacin, vitamin B6, folate, data from the Bogalusa Heart Study. Am. J. Clin. Nutr. 67:757S–763S, 1998.
(Leigh Beisch/Foodpix/PictureArts Corp.)

to soups and casseroles; fruit can be served on cereals or in milkshakes; cheese can be
included in recipes such as macaroni and cheese and pizza; milk can be added to hot
cereal, cream soups, and puddings; powdered milk can be used in baking; and meats
can be added to spaghetti sauce, stews, casseroles, burritos, and pizza.
Children often have periods known as food jags, when they will eat only certain
foods and nothing else. For example, a child may refuse to eat anything other than
peanut butter and jelly sandwiches for breakfast, lunch, and dinner. The general
guideline is to continue to offer other foods along with those the child is focused on.
What children will not touch at one meal, they may eat the next day or the next week.
Vitamin and mineral supplements are not necessary As

with adults, children who consume a varied diet based on healthy choices can meet all Supplements containing iron include
their vitamin and mineral requirements with food. Occasional skipped meals and un- the following on the label: “Warning:
finished dinners are a normal part of most children’s eating behavior and do not neces- close tightly and keep out of reach
sarily indicate that a supplement is needed. On the other hand, supplements that of children. Contains iron, which can
provide no more than 100% of the Daily Values are not harmful and may be benefi- be harmful or fatal to children in
cial for children with particularly erratic eating habits, those on regimens to manage large doses. In case of accidental
obesity, those with limited food availability, and those who consume a vegan diet. If a overdose, seek professional
children’s supplement is offered, it should be monitored by caregivers and stored assistance or contact a poison
safely. control center immediately.”
Nutritious meals at day care or school are important All

meals need to contribute to a child’s nutrient intake, but parents may have little input
into what children eat while at day care or school. Ensuring that meals eaten away
from home are nutritious is not easy because there is no guarantee that what is served
or brought from home will be eaten. A packed lunch should contain foods the child
likes and that do not require refrigeration (even if a refrigerator is available, the child
is likely to forget to put the lunch in it). Even the most carefully planned lunch doesn’t
provide nutrients if it is not eaten.
For children who buy their lunch at school, the National School Lunch Program
provides low-cost meals designed to meet nutrient needs and promote healthy diets.
The goals of this program are to improve the dietary intake and nutritional health of
America’s children, and to promote nutrition education by teaching children to make
appropriate food choices.11 Each lunch meal must provide one-third of the 1989
RDA for protein, vitamin A, vitamin C, iron, calcium, and energy and meet the Di-
etary Guidelines recommendations of no more than 30% of energy from fat and 10%
from saturated fat. Within these guidelines, each school or school district can decide
which foods to serve and how they are prepared. In addition to lunches, federal guide-
lines regulate foods sold in snack bars and vending machines that compete with school
lunch programs. These must provide at least 5% of the RDA for one or more of the
following: protein, vitamin A, vitamin C, niacin, riboflavin, calcium, and iron. An
analysis of the foods students choose to eat from the meal offered found that students
who participated in the school lunch program consumed one-third of the RDA for
energy, protein, vitamin A, vitamin C, vitamin B6, calcium, iron, and zinc and drank
twice as much milk as students not participating in school lunch programs.
Normal growth is the best indicator

of adequate intake
Children don’t always eat what and when they should, so how can you tell if they are
meeting their needs? The best indicator of adequate nourishment is a pattern of
growth that follows normal growth curves. Growth is most rapid in the first year of
life, when an infant’s length increases by 50%, or about 10 inches. In the second year
of life, children generally grow about 5 inches; in the third year, 4 inches; and there-
after, about 2 to 3 inches per year. During adolescence, there is a period of growth that
is almost as rapid as that of infancy.
Off the Label: Labeling Food

for Young Children
Children have different nutrient needs than adults. absence of percent Daily Values for total fat, saturated fat,
Therefore, the labels on foods designed for young children cholesterol, total carbohydrate, fiber, and sodium.1 Daily
must follow different rules. The most obvious difference Values for these nutrients have not been established for
relates to how fat is listed in the Nutrition Facts section. children under 4; for this age group, the FDA has set Daily
Labels for foods intended for children under 2 years of age Values only for vitamins, minerals, and protein. Labels
are not permitted to list the amount of saturated fat, include the percent Daily Values for these nutrients when
polyunsaturated fat, monounsaturated fat, cholesterol, they are present in significant amounts.
Calories from fat, and Calories from saturated fat on the A few nutrient and health claims are allowed on young
label.1 These labels are also not allowed to carry most of children’s foods. These include claims that describe the
the claims about a food’s nutrient content or health effects. percentage of vitamins or minerals in a food as they apply
This is because dietary fat is needed for brain development to the Daily Values for children under age 2, such as
and as an energy source during the rapid growth and “provides 50% of the Daily Value for vitamin C.” Also, for
development that occurs in infancy and early childhood. children under 2, the terms “unsweetened” and “unsalted”
Eliminating this information from the label may prevent are allowed. “No sugar added” and “sugar free” are
caregivers from restricting fats in the diets of young children. approved only for use on dietary supplements for children.
As children develop, the amount of fat in the diet can The labels of foods intended for young children provide
safely be reduced. Therefore, labels on foods designed for information needed to make wise food selections, but many
2- to 4-year-olds must include information on the amount of of the foods consumed by young children do not have special
cholesterol and saturated fat per serving and can voluntarily labels because they are also adult foods. When selecting
provide information on the number of Calories from fat these foods, keep in mind that the needs of young children,
and saturated fat and the amount of polyunsaturated and especially for fat, are different than the needs of adults.
monounsaturated fat per serving. The serving sizes listed
are based on servings appropriate for small children.
Reference
Another difference between standard food labels and 1. Kurtzweil, P. Labeling rules for young children’s foods. FDA Consumer 29:14–18,
those for foods designed for children under age 4 is the March 1995.
Nutrition Facts
Serving Size 1/4 cup (15g)
Servings Per Container About 30
Amount Per Serving

Calories 60
Total Fat 1g Nutrition Facts
Serving Size 1 jar (140g)
Sodium 0mg
Amount Per Serving
60
at
1g
0mg
Potassium 50mg Calories 110 Calories from Fat 0
Total F
50mg
Sodium
Po tas ium
rbohyd
rate
10mg
1g
Total Carbohydrate 10g T otal Fat 0g
Total Ca 0g
Fiber
Sugars
2g
Childre
n
Fiber 1g Saturated Fat 0g
Protein Infants 1-4 N
ut
0-1
6%
Sugars Cholesterol 0mg
Se
rv
rit
in
0g A g
Value 7% % m io Siz
% Daily
Ca oun nF e1
0 lo t Pe jar
0% % rie r Se ac (140
Protein 0 s ts g)
Sodium 10mg
rv
To 110 ing
A 0% %
Vitamin
ta
10 Ch S l Fa
Protein
at
15% 0% So ole urat t Calor
2g
C
Vitamin 6 diu ste ed Fa ies
from
45% 8% To m ro t Fat
Calcium ta l
Total Carbohydrate
0
Iron
15 % 0 %
45% 0%
3 27g lC
arb
Die oh
P S tary ydra
0g
0g
mVita in E 3
ro u
te gar Fibe te 0mg
45% 0% in s r
Thiamin
% 10mg
Ribofla
vin 25% 0%
15 %
2
1 Infants Children Dietary Fiber 4g P Da
ro il
V tein y V
it
Ir am 0% ue
al
27g
4g
Niacin
on in
% Daily Value 0-1 1-4

2% C 45 18g
us
oPh sphor %
Sugars 18g •
•
Vitam
Calciu in A 6%
0g
m 2%
Protein 7% 6% Protein 0g
Vitamin A 0% 0%
% Daily Value
Vitamin C 0% 0%
Protein 0% • Vitamin A 6%
Nutrition label for foods for Calcium 15% 10% Vitamin C 45% • Calcium 2%
children under age two Iron 45% 60% Iron 2%
Vitamin E 15% 8%
Thiamin 45% 30% Nutrition label for foods for children
Riboflavin 45% 30% ages two to four
Niacin 25% 20%
Phosphorus 15% 10%
Child and adolescent growth can be monitored by comparing growth to standard

patterns using growth charts (see Appendix B).12 For children and teens ages 2
through 20, weight-for-age, height-for-age, and BMI-for-age charts are available. The
BMI-for-age growth chart is the recommended method for identifying children and
adolescents who are over- and underweight (Figure 13.6).
Growth occurs in spurts and plateaus, but overall growth patterns are predictable.
The ultimate size (height and weight) that a child will attain is affected by genetic, en-
vironmental, and lifestyle factors. A child whose parents are 5 feet tall may not have
the genetic potential to grow to 6 feet, but when adequately nourished, most children
follow standard patterns of growth. If a child’s overall pattern of growth changes, his
or her dietary intake should be evaluated to determine the reason for the sudden
change. There are critical periods in childhood when malnutrition can cause lasting
damage to physical, emotional, and cognitive development for which adequate nutri-
tion later on may not be able to compensate.5
Too little growth may mean undernutrition When a child’s

calorie intake is too low to meet needs, weight will decrease. If the deficiency contin-
ues, growth in height will slow or stop. A child who falls below the fifth percentile of
the BMI-for-age distribution is considered underweight and should be evaluated to
CDC Growth Charts: United States
BMI BMI
97th
34 34
Body mass index-for-age percentiles: Over-
32 Girls, 2 to 20 years weight 95th 32
30 30
At risk
90th
28 28
85th
26 26
75th
24 24
Normal
22 50th 22
20 25th 20
18
10th
5th
FIGURE 13.6
18
3rd
Growth charts are helpful for monitoring
16 16 a child’s pattern of growth. This example
Under-
weight illustrates BMI-for-age percentiles for
14 14 girls ages 2 through 20. BMI can be used
beginning at 2 years of age, when height
can be measured accurately. BMI is
12 12
predictive of body fat and has been
kg/m2 kg/m2 recommended to screen for underweight
and overweight children, ages 2 years
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
and older. The colored areas represent
Age (years)
BMI values that are associated with
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the Nation Center for Chronic Disease Prevention and Health Promotion (2000).
CDC
CENTER FOR DISEASE CONTROL
AND PREVENTION
underweight, normal weight, at-risk
of overweight, and overweight.
determine the cause of his or her low body weight (see Figure 13.6). Nutritional inter-
ventions such as offering children small, frequent, nutritious meals and snacks can in-
crease energy intake and help increase body weight. Underweight adolescents can
increase their weight by combining muscle-building exercises with increases in energy
intake.
A high BMI may indicate a risk of becoming overweight

A drastic increase in BMI may be due to an energy intake that exceeds output. Re-
search has found that overweight children and adolescents are more likely than their
normal-weight counterparts to be overweight as adults.13 As with adults, excess body
weight in childhood and adolescence increases the risk of chronic disease. A child is
considered overweight when BMI falls at or above the 95th percentile and is at risk of
being overweight when BMI is greater than or equal to the 85th percentile and less
than the 95th percentile (see Figure 13.6).
Excessive weight gain in children is related to both eating and exercise habits. Re-
ducing weight into the healthy range involves a permanent change in lifestyle. Because
children, like adults, may overeat for comfort, self-reward, or out of boredom, parent
involvement in helping the child find other sources of gratification can be vital.
Mild calorie restriction can allow for growth with little

weight gain The goal of weight management for children and teens is to slow
their rate of weight gain and allow them to grow into their current weight. As long as
the rate of weight gain is slowed, a child at the 95th percentile for weight at age 7 can
be at the 90th percentile by age 9 and at the 75th percentile by age 11. The diet
should be moderate in calories and include whole grains, fruits and vegetables, lean
meats, and reduced-fat dairy products. Both meals and snacks are important. Break-
fast and lunch are important because skipping meals may actually increase energy in-
take by increasing the amount of food consumed later in the day. Denying food may
promote further overeating by making the child feel that there will not be enough to
satisfy hunger. Planning ahead can help manage eating at social events. For example, a
teenage boy with a weight problem could plan how much he will eat at a pizza party
and then increase his exercise to burn off the excess calories.
Increasing physical activity increases energy expenditure

Although energy intake among American children overall is not increasing, they are
getting heavier, suggesting that a major contributor to the increase in body weight is
lack of physical activity.14 Watching television, playing video games, and surfing the
Web have replaced neighborhood games of tag and soccer for many children (Figure
13.7).
Overweight children are less likely to be physically active than lean children.
They may be embarrassed by their bodies and shy away from participating in
group activities. Increases in physical activity need to be gradual in order to make
exercise a positive experience. A good way to start is to encourage activities such as
games, walks after dinner, bike rides, hikes, swimming, and volleyball that can be
enjoyed by the whole family. This sends a positive message to “be more active”
rather than a negative message of “do not eat so much.” Again, involvement of the
whole family is key. Parents who are active, play with their children, watch their
children compete or play, or take children to physical activities or sports events
have more active children.
Whether or not a child is overweight, he or she should be active. The Dietary
Guidelines and the DRIs recommend that children be physically active for at least an
hour per day.15 Children have short attention spans, so their activities should be inter-
FIGURE 13.7 mittent. Periods of moderate to vigorous activity lasting 10 to 15 minutes or more
each day should be interspersed with periods of rest and recovery. Preadolescent chil-
Video games provide children with an inactive dren should be exposed to a variety of different types of activities that are of various
way to spend their spare hours. (Mel Yates/ levels of intensity (Figure 13.8). Learning to enjoy sports and exercise in childhood
Taxi/Getty Images) will set the stage for an active lifestyle in adulthood.
Fitness Pyramid for Kids

RED
ZONE
Jumping
rope
Stair climbing
Frequency: 1 time per week Sprinting or
Intensity: 90%–100% of HRM* jogging fast
Time: 1–5 minutes High-intensity
aerobic exercise
POWER ZONE
Frequency: 2 times per week Soccer Tennis
Intensity: 80%–95% of HRM Running Gymnastics
Time: 5–10 minutes Basketball Ice skating
Racquetball Cross country skiing
KICK IT ZONE Frequency: 3 times per week

Intensity: 70%–85% of HRM
Swimming Canoeing Time: 15–30 minutes
Wallyball Cycling
In-line skating Walking (5 miles per hour
Downhill skiing or 2.5 miles in 30 minutes)
HEALTHY HEART ZONE

Frequency: 4–5 times per week
Volleyball Table tennis (1 game) Intensity: 50%–70% of HRM
Dancing Walking (3– 4 miles per hour Time: 30 minutes
Hunting or 15 minutes each mile)
FAT BURNING ZONE

Frequency: 6 times per week Playtag Bowling Horseshoes
Intensity: 40%–50% of HRM Hopscotch Sledding Fishing
Time: 60 minutes Softball Sailing Badminton
Golf Biking Archery
*HRM—Heart Rate Maximum

(Adapted from: American Dietetic Association. Position of the American Dietetic Association: Dietary guidance for healthy children ages 2 to 11 years. J. Am. Diet.
Assoc. 99:93–101, 1999)
FIGURE 13.8
Children should enjoy participating in a variety of activities of varying intensity.
Diet and lifestyle affect nutritional risks For more information

in children on weight control in
children, go to the
A number of diet and lifestyle factors can put children at risk for illness and malnutri- National Institute of
tion. Some of these are a greater risk in young children because of their size and stage Diabetes and Digestive
of development and others may continue to be problems into adolescence. and Kidney Disorders at
www.niddk.nih.gov and click on “weight
A high sugar intake reduces nutrient density and pro- loss & control” under Health Information.
motes tooth decay Children often eat more sugar than is recommended.
Added sugars reduce the nutrient density of foods and too many foods high in added
sugars make it difficult to meet nutrient needs. In addition, a diet high in sugary foods
promotes tooth decay. Decay occurs when there is prolonged contact between sugar
and bacteria on the surface of the teeth.
Much of the added sugars in children’s diets come from soft drinks and other
sweetened beverages; when these are sipped slowly between meals the contact time be-
tween sugar and teeth increases and hence, increases the risk of tooth decay. Although
sugary foods are the most cavity-promoting, any carbohydrate-containing food can
cause tooth decay, especially if the food sticks to the teeth (see Chapter 4).
Preventing tooth decay involves limiting carbohydrate snacks, especially those that
stick to teeth; brushing teeth frequently to remove sticky sweets; and consuming ade-
quate fluoride (Figure 13.9). Because the primary teeth guide the growth of the per-
manent teeth, maintaining healthy primary teeth is just as important as preserving
FIGURE 13.9
Frequent tooth brushing can help prevent cavities in
children. (David Young-Wolff/PhotoEdit)
permanent ones. Children’s teeth should be brushed as soon as they erupt, and those 3
years of age and over should be examined by a dentist regularly.
Hyperactivity has not been found to be related to sugar

intake Diet, in particular sugar intake, has been blamed for hyperactivity in chil-
dren. Hyperactivity is a problem in 5 to 10% of school-age children, occurring more
frequently in boys than in girls. It involves extreme physical activity, excitability, im-
pulsiveness, distractibility, short attention span, and a low tolerance for frustration.
Hyperactive children have more difficulty learning but usually are of normal or above-
average intelligence. Hyperactivity is now considered part of a larger syndrome known
▲* Attention deficit hyperactivity as attention deficit hyperactivity disorder.
disorder A condition that is characterized Although sugar is often blamed for hyperactivity, research on sugar intake and be-
by a short attention span and a high level havior has failed to support this hypothesis.16 The hyperactive behavior that follows
of activity, excitability, and distractibility. sugar intake is more likely due to other factors. For example, at a birthday party the
excitement rather than the sugary cake that is served is a more likely reason for over
activity. Other situations that might cause hyperactivity include lack of sleep, over-
stimulation, the desire for more attention, or lack of physical activity.
Specific foods and food additives have also been implicated as a cause of hyperactivity.
Numerous studies have been done to test the hypothesis that food sensitivities cause
hyperactivity, but the results have been inconsistent.17 Some children with this disorder
seem to improve when particular foods or additives are eliminated, while others do not.
Another possible cause of hyperactive behavior in children is caffeine. Caffeine is a
stimulant that can cause sleeplessness, restlessness, and irregular heartbeats. Beverages,
food, and medicines containing caffeine are often a part of children’s diets. For exam-
ple, children’s fast-food meals are typically accompanied by caffeinated beverages such
as Coke and Mountain Dew.
Lead from the environment harms the developing ner-

vous system Lead is an environmental contaminant that can be toxic, especially
in children under 6 years of age. Children are particularly susceptible because they ab-
sorb lead much more efficiently than do adults. It is estimated that children may ab-
sorb as much as 30 to 75% of ingested lead, whereas adults absorb only about 11%.18
Once absorbed from the gastrointestinal tract, lead circulates in the bloodstream
and then accumulates in the bones and, to a lesser extent, the brain, teeth, and kid-
neys. Lead disrupts the functioning of neurotransmitters and thus interferes with the
100
80
Percent of 60
children aged
1–5 years
with blood 40
lead ≥ 10µg/dL
20
FIGURE 13.10
The prevalence of children ages 1 to 5 with elevated blood lead levels has
1976–1980 1988–1991 1991–1994 1999–2000 decreased dramatically over the last 25 years due to interventions such as
Years Surveyed the elimination of lead from paint, gasoline, and solder. Source: NHANES.
functioning of the nervous system. Higher levels of lead can contribute to iron defi-
ciency anemia, changes in kidney function, nervous system damage, and even seizures,
coma, and death. In young children, lead poisoning can cause learning disabilities and
behavior problems.19 In adults, lead poisoning can damage the reproductive organs
and cause high blood pressure.20 During pregnancy, lead toxicity can damage the fetal
nervous system.
Lead is found naturally in the earth’s crust, but over the years industrial activities
have redistributed it in the environment. Lead is now found in soil contaminated with
lead paint dust; it also enters drinking water from old corroded lead plumbing, lead
solder on copper pipes, or brass faucets. It is found in polluted air, in leaded glass, and
in glazes used on imported and antique pottery. These can contaminate food and bev-
erages. Because of the risks of lead toxicity from environmental contamination, lead is
no longer used in house paint, gasoline, or solder. As a result, the number of children
with elevated blood lead levels has decreased dramatically (Figure 13.10).21 The U.S.
Department of Health and Human Services has established a national goal of elimi-
nating blood lead levels greater than 10 g per dL in children younger than 6 years of
age by 2010.19 Despite these gains, there are still nearly a million children under 6
years of age who have blood lead levels that are high enough to cause damage. For a
number of reasons, the problem is greatest among children living in poverty. Their ex-
posure is likely to be greater because they tend to live in older buildings where
chipped paint and old plumbing may be contaminated with lead. In addition, chil-
dren living in poverty are more likely to be malnourished, and malnutrition increases
lead absorption because lead is better absorbed from an empty stomach and when
other minerals such as calcium, zinc, and iron are deficient.
Children should have their blood lead levels tested.19 The effects of lead poisoning
are permanent, but if high levels are detected early, the lead can be removed with med-
ical treatment, preventing damage (Table 13.2).
Too much television reduces activity and influences

food choices Many children today spend more time watching television than
they do in any activity other than sleep. Television affects nutritional status in a num-
ber of ways: it introduces children to foods they might otherwise not be exposed to, it
promotes snacking, and it reduces physical activity (Figure 13.11).
Through advertising, television has a strong influence on the foods selected by
young children. A review of commercials broadcast during children’s programming
found that over 60% were for food products—primarily sweetened breakfast cereals;
sweets such as candy, cookies, doughnuts, and other desserts; snacks; and beverages—
that are high in sugar, fat, or salt.22 Television also promotes snacking behavior. Al-
though snacks are an important part of a growing child’s diet, while watching TV
many children snack on sweet and salty foods that are low in nutrient density.
TABLE 13.2
What You Can Do to Reduce Lead Exposure
Reducing exposure from lead paint: If you live in a house built before 1978, it
may contain lead paint or lead paint may have been sanded or scraped off at
some time.
• Wash floors and other surfaces weekly with warm water and detergent.
• Wipe soil off shoes before entering the house.
• Cover exposed soil in the yard with grass or mulch.
Reducing exposure from tap water: If your home has old plumbing, lead may be
leaching into your tap water. More lead leaches into hot water than cold, and
water that has been standing in the pipes has more lead.
• Use cold water for drinking and cooking.
• Allow water to run for 30 seconds before use.
Reducing exposure from food containers: Pottery glazes and lead crystal contain
lead. The FDA limits the amount of lead allowed in ceramic foodware, but the
lead content of pottery designed for ornamental use is not regulated.
• Look for engraved warnings such as “Not for Food Use—May Poison Food”
and “For Decorative Purposes Only” to identify pottery that should not be
used to serve food.
• Do not store acidic foods such as fruit juices or tomato juice in ceramic
containers.
• Limit the use of antique or collectible housewares for food or beverages to
special occasions.
• Use your lead crystal stemware to drink from, but do not store beverages in
lead crystal.
• Pregnant women should not routinely use lead crystal glasses.
• Infants should not be fed from lead crystal baby bottles.
For additional information: Go to the Centers for Disease Control and Prevention
at www.cdc.gov/health/lead.htm or the Environmental Protection Agency’s
National Lead Information Center at www.epa.gov/lead/nlic.htm
Perhaps the most important nutritional influence of television is that it reduces ac-
tivity. Hours spent watching television are hours when physical activity is at a mini-
mum. One study showed that children who watch 4 or more hours of TV per day had
more body fat and a greater BMI than those who watch fewer than 2 hours a day.23 In
addition to television, children and adolescents today replace time spent at more phys-
ically demanding activities with time spent playing computer and video games.
Fats, Oils,
Milk, Cheese, & Sweets
Meat, Poultry, Fish,
& Yogurt Dry Beans, Eggs,
& Nuts
Bread, Cereal, Rice,
& Pasta
Saturday Morning Pyramid

FIGURE 13.11
Watching television reduces activity level and increases snacking. The advertisements shown on television also influence the kinds of foods children
choose. (Donna Day/Stone/Getty Images). The “Saturday Morning Pyramid” shown on the right illustrates the percentage of foods in different Food
Guide Pyramid groups that are advertised during children’s Saturday morning television. A high percentage of these foods are high in fat or sugar
and low in nutrient density. No foods fitting into either the vegetable or the fruit groups were advertised. (Kotz, K., and Story, M. Food advertisements
during children’s Saturday morning television programming: are they consistent with dietary recommendations? J.Am. Diet.Assoc. 94:1296–1300, 1994)
Adolescents Have Changing Bodies and High Nutrient Needs 459
So, What Should I Eat?
Serve children frequent nutritious meals and snacks

• Smear a banana or an apple with peanut butter
• Offer some carrots with yogurt dip
• Try to have at least four colors with every meal
• Cut and arrange healthy foods in interesting shapes
Sneak in more fruits and vegetables
• Bake bananas and berries into breads and muffins
• Add vegetables to soups and casseroles
• Blend fruit into shakes and smoothies
• Mix extra vegetables into spaghetti sauce
• Stuff more tomatoes on your taco
Include calcium where you can
• Have macaroni and cheese
• Make oatmeal with milk rather than water
• Make cream soup by adding milk
• Serve pudding or custard
Add iron
• Make your spaghetti sauce with meat
• Cook your stew in an iron pot
• Beef up your tacos and burritos
• Have an iron-fortified breakfast cereal
Adolescents Have Changing Bodies

and High Nutrient Needs
The physical changes associated with sexual maturation begin to occur between 9 and
12 years of age. These physical changes, along with the social and psychological
changes that accompany them, have a significant impact on the nutritional needs and
nutrient intakes of adolescents.
Hormones cause sexual maturation and

changes in body size and composition
During adolescence, organ systems develop and grow, body composition changes, and
the growth rates and nutritional requirements of boys and girls diverge. This period of
rapid change, which ends in sexual maturation, is called puberty. During this time, ▲* Puberty A period in life characterized
boys and girls grow about 11 inches and gain about 40% of their eventual skeletal by rapid growth and physical changes that
mass.24 From ages 10 to 17, girls gain about 53 pounds and boys about 70 pounds. ends in the attainment of sexual maturity.
During this time, there is an 18- to 24-month period of peak growth velocity, called
the adolescent growth spurt. In girls, the growth spurt occurs between the ages of 10 ▲* Adolescent growth spurt An 18- to
and 13. In boys, it occurs between ages 12 and 15. During the growth spurt, boys 24-month period of peak growth velocity
gain some fat but add so much lean mass as muscle and bone that their percentage of that begins at about ages 10 to 13 in girls
body fat actually decreases (Figure 13.12). Girls gain proportionately more body fat and 12 to 15 in boys.
and less lean tissue than boys. These physiologic changes affect nutrient needs. Be-
cause there is a large individual variation in the age at which these growth changes
occur, the stage of maturation is often a better indicator of nutritional requirements
than actual chronological age.
100
80
Average body composition

60 LBM
LBM
(percent)
Acne is a common problem during 40
adolescence.At one time it was
believed to be related to diet, and
long lists of foods to avoid were
doled out to teens with acne.We now
20 FAT
know that heredity and changes in
hormone levels play a major role in
the development of acne, and that FAT
anxiety, lack of sleep, and hormonal
fluctuations are more likely to cause 0
15-year-old 15-year-old
acne flare-ups than specific foods. boy girl
Despite the fact that specific foods FIGURE 13.12
do not cause acne, a well-balanced
diet is important for ensuring that After puberty, males have a higher percentage of lean body mass and less body fat than females. (Adapted from
the skin has all the nutrients needed Forbes, G. B. Body composition. In Present Knowledge in Nutrition, 6th ed. Brown, M. L. ed. Washington, DC:
to maintain its integrity. International Life Sciences Institute-Nutrition Foundation, 1990)
Total energy and nutrient needs are greatest

during adolescence
The proportion of calories from carbohydrate, fat, and protein recommended for ado-
lescents is similar to that of adults, but the total calories needed by teenagers exceed
adult needs. Energy requirements for boys are greater than those for girls because boys
have more muscle and a greater body size. Protein requirements per kilogram of body
weight are the same for boys and girls, but since boys are generally heavier, they re-
quire more total protein than girls. These higher requirements for males continue
throughout life. The DRIs for adolescent intake begin at age 9 and divide recom-
mended intakes into two adolescent age groups: 9 through 13 and 14 through 18. Be-
cause the needs of boys and girls begin to differ during the adolescent years, separate
recommendations are made.
Vitamin needs are increased by growth and high energy

expenditure The need for many of the vitamins is greater during adolescence
than at any other time of life. For example, the requirement for B vitamins, which are
involved in energy metabolism, is much higher in adolescence than in childhood be-
cause of higher energy intakes. Riboflavin is frequently low in teen diets, especially in
those of girls, possibly due to low milk intake. Vitamin B6 is needed for protein syn-
thesis; therefore, need is increased during the rapid growth of adolescence. Folate and
vitamin B12 needs are increased because of the rapid rate of cell division for tissue
growth. Vitamin B12 intake is typically adequate, but folate is a vitamin at risk for de-
ficiency in the adolescent population.25 The need for vitamin D increases with skeletal
growth. The AI for vitamin D is set at 5 g per day. Although many teens do not
drink the recommended amount of milk, which is a good source of vitamin D, active
teens who engage in outdoor activities, are able to synthesize much of the vitamin D
they need. Additional amounts of vitamins A, C, and E are needed to preserve the
structure and function of the newly synthesized cells. Adequate amounts of these are
generally consumed by teens.26
The iron needs of adolescent girls are even higher than

those of boys Iron deficiency anemia is common in adolescence. Iron is
needed to synthesize hemoglobin for the expansion of blood volume and myoglobin
for the increase in muscle mass. Because blood volume expands at a faster rate in boys
than in girls, boys require more iron for tissue synthesis than girls. However, in girls,
the onset of menstruation increases iron losses, making total needs greater in young
women. The RDA is set at 11 mg per day for boys and 15 mg per day for girls ages 14
to 18. Young women typically consume less than the recommended amount. Iron de-
ficiency occurs in about 9% of girls ages 12 to 15 and 16% of young women ages 16
to 19.27 Good sources of iron acceptable to teens include fortified grains and breakfast
cereals and lean red meats.
Increases in bone length and mass increase calcium

needs The adolescent growth spurt increases both the length and the mass of
bones, and adequate calcium is essential to form healthy bone. Calcium retention
varies with growth rate, with the fastest-growing adolescents retaining the most cal-
cium. The AI for calcium during adolescence is 1300 mg per day for both sexes, but
intake is typically below this in both adolescent boys and girls.24 This may compro-
mise the level of peak bone mass achieved, increasing the risk of developing osteo-
porosis later in life. Foods common in the teen diet that are good sources of calcium
FIGURE 13.13
include milk, yogurt and frozen yogurt, ice cream, and cheese added to hamburgers,
nachos, and pizza (Figure 13.13). Although milk and cheese are the biggest source of These foods, which are common choices for
calcium in teen diets, they can be high in saturated fat, so adolescents should be en- teens, are good sources of calcium but some
couraged to consume low-fat dairy products, calcium fortified cereals, and vegetable can also be high in calories, saturated fat,
sources of calcium. cholesterol, sugar, or sodium. (George Semple)
Mild zinc deficiency can affect growth and development

During adolescence, the increase in protein synthesis required for the growth of skele-
tal muscle and the development of organs increases the need for zinc. The RDA is 11
mg for boys and 9 mg for girls ages 14 to 18. A long-term deficiency results in growth
retardation and altered sexual development. Although severe zinc deficiency is rare in
developed countries, even mild deficiency can cause poor growth, affect appetite and
taste, impair immune response, and interfere with vitamin A metabolism. Since ado-
lescents are growing rapidly and maturing sexually, adequate zinc is essential for, but
not typically consumed by, this age group.26 Good sources include meats and whole
grains.
Teens must learn to make healthy

choices to meet nutrient needs
As with children, the nutrient intake of adolescents is affected by psychosocial devel-
opment and the environment in which they live. Skipped meals and meals away from
home are common among adolescents. A food is more likely to be selected because it
tastes good, it is easy to grab, or friends are eating it than because it is healthy. The
best indicators of adequate intake are satiety and growth that follows the curve of the
growth charts. No matter when foods are consumed throughout the day, an adoles-
cent’s diet should follow the recommendations of the Food Guide Pyramid—choosing
at the high end of the range of serving recommendations. For example, a diet contain- Only about a third of teens
ing 3000 or more Calories should contain 11 servings of grains. This may seem like a consume the number of servings
staggering number, but it is not when spread over the course of a day. A large bowl of of vegetables recommended by
cereal and two slices of toast for breakfast is 4 servings; two tacos for lunch and crack- the Food Guide Pyramid, and only
ers after school provide 4 more servings; and a dinner of spaghetti and garlic bread can 11% of boys and 16% of girls eat
add another 3 or 4 servings. The diet should also provide 5 to 9 servings of fruits and the recommended number of
vegetables. Unfortunately, fruits and vegetables are the food groups most likely to be servings of fruit.
lacking in the American diet: french fries, which are high in fat and salt, are the most
frequently consumed vegetable. And many people never consume fruit. Sources of
fruits and vegetables acceptable to teens include fruit juice, salads, and tomato sauce
and vegetables on pizza and spaghetti.
Fast food and sugared cereal Since the teen diet, especially that of teenage boys, is typically high in fat, saturated
can be part of a healthy diet fat, cholesterol, and sodium, meals offered at home should be low in fat and sodium.
Teens are no longer fed by their parents, but healthy choices, such as reduced-fat milk
as long as these choices are and dairy products, vegetables, and fruits, should be available at home.
consumed in moderation and
balanced with a variety of
nutritious choices. Fast food needs to be balanced with healthier choices
Children and teens generally love fast food, and there is nothing wrong with an occa-
sional fast-food meal (Figure 13.14). But a steady diet of burgers, fries, and tacos will
likely contribute to an overall diet that is high in calories, fat, and salt and low in cal-
cium, fiber, and vitamins A and C. The few pieces of shredded lettuce and chopped
tomatoes that garnish your burger or taco are not enough to meet the serving recom-
mendations for vegetables. Typical fast food meals are also lacking in milk and fruits. To
fit fast food into a healthy diet, more nutrient-dense, fast-food choices can be made and
other meals and snacks throughout the day need to supply the missing nutrients. Many
fast-food franchises now offer fruits, salads, and milk. And some of the old standbys are
not bad choices. A plain, single-patty hamburger provides a lot less fat and energy than
one with two patties and a high-fat sauce. A chicken sandwich can be a healthy choice if
FIGURE 13.14 it is grilled or barbecued, not breaded and fried (see Nutrient Composition of Foods
booklet). French fries are high in fat and calories, but can be part of a healthy diet if con-
Eating fast food doesn’t necessarily make sumed in moderation. A fast-food meal is only one part of the total diet. If the missing
your overall diet unhealthy.(Chris Hackett/ milk, fruits, and vegetables are consumed at other times during the day, the total diet
Photographer’s Choice/Getty Images) can still be a healthy one.
Balance less healthy choices with healthy ones

• Have milk with your burger and fries
• Eat an extra vegetable with dinner
• Put peppers on your pizza
• Try fresh fruit for dessert
Eat breakfast
• Grab some toast with peanut butter
• Stick a cereal bar or muffin in your backpack
• Have a yogurt on the go
Snack well
• Reach for an apple, pear, or orange before the cookies and chips
• Dip your chips in salsa, guacamole, or hummus
• Nibble on nuts and seeds
• Crunch some baby carrots
Count up your calcium
• Drink milk instead of soda and juice drinks—low-fat milk has fewer calories than soda
• Put extra milk on your cereal
• Make a shake by mixing milk and fruit in the blender
• Have cheese with crackers, on pizza, or in tacos
Vegetarian diets are not always as healthy as they could

be Some children and teens consume vegetarian diets because their families are vege-
tarian, but teens may also decide to consume a vegetarian diet even if the rest of the
family does not. Some give up meat for health reasons or to lose weight, but most give
up meat because they are concerned about animals and the environment. Although
vegetarian diets can be a healthful alternative, they must be carefully planned to meet
needs and avoid excesses. Getting enough protein is generally not a problem with veg-
etarian diets, except for small children, but meatless diets can be low in iron and zinc.
Vegan diets, which contain no animal products, may put teens at risk of vitamin B12
deficiency and inadequate calcium intake. We generally think of vegetarian diets as
being low in fat, but if they include high-fat dairy products they can be high in satu-
rated fat and cholesterol fat. For instance, a slice of cheese pizza and a can of cola is a
high-fat, high-sugar vegetarian choice. However, when chosen carefully, a vegetarian
diet can be low in saturated fat and cholesterol and high in complex carbohydrate,
fiber, and micronutrients.
Concerns about appearance and performance

can precipitate nutritional problems
The teenage years are ones of experimentation as teens try to find their place in the
world. Nutrient intake is generally not a major concern. Social activities and peer
pressure, as well as taste and convenience have more of an impact on food choices
than the nutrients these foods provide. Appearance is probably of more concern dur-
ing adolescence than at any other time in life. Many girls want to lose weight even if
they are not overweight. Some boys also want to reduce their weight, but many want
to gain weight to achieve a muscular, strong appearance and enhance their athletic
abilities. Social activities and peer pressure also promote alcohol consumption among
teens. The risks associated with alcohol consumption are discussed at the end of the
chapter.
Eating disorders are most common in adolescence Eating

disorders are most common in teenage girls and young women; but they are becoming
more and more common in younger children. Eating disorders are usually not diag- Many teenage girls want to look like
nosed until adolescence, but the excessive concern about weight, low self-esteem, and fashion models, and this societal
poor body image that characterizes these conditions may begin as early as the pressure is affecting younger and
preschool years. As children grow the pressure of taking on the responsibilities of younger girls. About 40% of girls in
adulthood, combined with pressure from peers and society to be thin, may contribute 1st through 3rd grades want to be
to the development of eating disorders (see Chapter 7). Many people with eating dis- thinner and 80% of 10-year-olds
orders feel ineffectual in their lives and may be using food to achieve some measure of are afraid of being fat. Refer to
self-control. The nutritional consequences of an eating disorder can affect growth and Chapter 7 for more information
development and have a lifelong impact. on eating disorders.
Athletes may use supplements and diets to enhance

performance Despite all the benefits of exercise, the nutrition misinformation
that is common in school athletics can lead to serious health problems. The use of di-
etary supplements, anabolic steroids, inappropriate training diets, and fad diets can all
cause problems (see Chapter 11).
Teen athletes may require more water, energy, protein, carbohydrate, and micronu-
trients than their less active peers, but supplements are rarely needed to meet these
needs. If the extra energy needs of teen athletes are met with whole grains, fresh fruits
and vegetables, and dairy products their protein, carbohydrate, and micronutrient
needs will easily be met. An exception is iron, which may need to be supplemented,
particularly in female athletes. The combination of poor iron intake, iron losses from
menstruation and sweat, and increased needs for building new lean tissue puts many
female athletes at risk for iron deficiency anemia.28
Some of the most dangerous practices associated with adolescent sports are those
that attempt to control body weight. Some sports such as football demand that the
athlete be large and heavy. In order to “bulk up,” high school athletes may experiment
with anabolic steroids, androstenedione, and creatine (see Chapter 11). Anabolic
steroids are illegal, and although they do increase muscle mass, the risks far outweigh
the benefits. Androstenedione is a testosterone precursor that the FDA has asked sup-
plement manufacturers to remove from their products due to concerns about safety.
Creatine improves exercise performance in sports requiring short bursts of activity and
has not been associated with serious side effects.29 Nonetheless, the best and safest way
for young athletes to increase muscle mass is the hard way—lifting weights and eating
more.
Success in some sports depends on being light and lean. Athletes involved in sports
such as gymnastics and wrestling may restrict their food intake in order to keep their
weight low. Weight restriction, however, may affect nutritional status and maturation
and increase the risk of developing an eating disorder.30 In female athletes, the combi-
nation of hard training and weight restriction can lead to a syndrome referred to as the
female athlete triad, which includes disordered eating, amenorrhea, and osteoporosis
(see Chapter 11). In male athletes who participate in sports such as wrestling that re-
quire athletes to fit into a specific weight class on the day of the event, dangerous
methods of quick weight loss are a concern. Severe energy intake restriction, water de-
privation, self-induced vomiting, and diuretic and laxative abuse are common prac-
tices among wrestlers. Low-calorie diets can interfere with normal growth and may be
too limited in variety to meet these athletes’ needs for vitamins and minerals. Restrict-
ing water intake and encouraging sweat loss to decrease body weight may be even
more dangerous. These practices allow the temporary weight loss necessary to put the
athlete in a lower weight class, but the resulting dehydration is dangerous and can im-
pair athletic performance.31 Fluids should be consumed before, during, and after exer-
cise to prevent dehydration.
Good Nutrition Can Keep Adults Healthy

The benefits of a healthy diet do not stop when you stop growing. Good nutrition
throughout your adult years can keep you healthy and active into your 80’s and be-
yond. As you age your body changes. Some of these changes are inevitable, and some
are due to disease processes, but all of them can be affected by your nutritional health.
In turn, these changes affect nutritional status and can increase the risk of malnutrition.
Aging begins at birth

When are you old? The answer may depend on who is defining the term. To a 5-year-
old, anyone over age 15 seems old, but to a healthy 80-year-old, “old” may mean 90.
Whether you are 6 or 60, you are aging; it is a process that begins with conception
and continues throughout life (Figure 13.15). Aging is an inevitable accumulation of
changes over time that increase susceptibility to disease and death. But, chronological
age is not always the best indicator of health. A person who is chronologically 75 may
have the vigor and health of someone who is 55, or vice versa. Some 70-year-olds are
out riding bicycles and hiking while others have difficulty getting around on their
own; some older people are healthy, independent, and active, while others are chroni-
cally ill, dependent, and at high risk for malnutrition. Aging is universal to all living
things, but it is a process we still don’t fully understand. We do know that our genetic
makeup and the environment and lifestyle in which we spend our years affect how
long we live and how long we remain healthy.
FIGURE 13.15
Aging is caused by a decrease in cell number and func-
Aging is a process that occurs continuously tion As we get older, the number of cells in our body decreases and the function of
in individuals of all ages. (Tony Freeman/ the remaining cells declines. This reduces our ability to perform the physiological
PhotoEdit) functions necessary to maintain homeostasis. This loss of cells and cell function occurs
throughout life, but the effects are not felt for many years because we start out life
Good Nutrition Can Keep Adults Healthy 465
with more cells and more cell function than we need. As a person ages the loss of cells
begins to have an impact on how well the body operates. As functional capacity de-
clines the effects of aging become evident in all body systems. The body also loses its
ability to repair damage so older people may die from a disease that they could have
easily recovered from when they were younger.
We don’t completely understand why cell number and function declines over time In young adults, the functional
but there are a number of hypotheses. One states that aging is programmed in our capacity of organs is four to ten
genes. This means that we each come into the world with a biological clock that is set times that required to sustain life.
to go off at a particular time, give or take a few years. When that clock goes off it sig-
nals our bodies first to age and then to die. Another hypothesis suggests that we age as
a result of the wear and tear of our lives. Exposure to toxins, illnesses, a poor diet, ex-
cessive use of alcohol, cigarette smoking, excess sun exposure, and many other physi-
cal and emotional stresses will wear things out more quickly. One of the sources of
this wear and tear is free radicals. Free radicals, generated from both normal metabolic
processes and exposure to environmental factors, cause oxidative damage to proteins,
lipids, carbohydrates, and DNA in our bodies. This damage done by free radicals is
associated with aging and has been implicated in the development of a number of
chronic diseases common among older adults, including cardiovascular disease and
cancer.
How long you live is determined by your genes,

lifestyle, and environment The rate at which we age and how long we
live depends on the genes we inherit as well as our lifestyle, and the extent to which
we are able to avoid accidents, disease, and environmental toxins (Figure 13.16).
Genes determine our susceptibility to age-related diseases such as cardiovascular dis-
ease and cancer. But the lifestyle we choose and the environment in which we live also
affect how fast we age. For example, a person with a family history of heart disease To predict your life
who eats a healthy diet and exercises regularly may never develop heart disease. In expectancy go to the life
contrast, someone with no heart disease in their family but who is inactive, smokes expectancy calculator at
cigarettes, and eats poorly may develop heart problems. www.livingto100.com/
Most of us are not healthy for all of our later years How
long can people live? Human life span is about 100 to 120 years, but most people do ▲
* Life span The maximum age to which
not live that long. In the United States today, people live an average of 77.2 years.32 members of a species can live.
This average life expectancy varies between and within populations. In the United
States, it is greater in women than in men and it is higher in Caucasians than in ▲* Life expectancy The average length
African Americans. It is lower in developing countries where access to good nutrition of life for a population of individuals.
and adequate health care are limited (see Chapter 15). Due to advances in technology
and improved nutrition and health care, life expectancy in the United States has in-
creased over the years.
Environment Lifestyle
Disease Nutrition
Accidents Rate Exercise
Toxins of aging Stress
FIGURE 13.16
Genetics
Susceptibility to The rate at which individuals age is affected
environmental stress by their genetic makeup, the environment in
Ability to repair cellular
which they live, and the lifestyle choices they
damage
make.
80
60
Number of
persons 40 older
(millions) 65 or
20
85 or older
0
1900 1950 2000 2050
Year Projected
FIGURE 13.17
This graph illustrates the increase in the total number of persons age 65 and older and 85 and older from 1900 to
2050. Data through 2050 are based on projections of the population and indicate that in the next few decades
there will be almost 80 million people in the United States who are 65 or older. (U.S. Census Bureau. Decennial
Census Data and Population Projections. Available online at www.agingstats.gov)
Even though average life expectancy in the United States is over 77 years, the aver-
age healthy life span is only about 69 years.33 This means that on average the last 8
years of life are restricted by disease and disability. The goal of successful aging is to in-
crease not only life expectancy but the number of years of healthy life that an individ-
ual can expect. Achieving this goal is important because we live in an aging
A person born in the United States in population. Currently about 12.4% of the U.S. population is 65 years of age or over
2000 has a life expectancy of about and this is expected to increase to about 19.6% by the year 2030 (Figure 13.17).34
77 years. For someone born in 1900, The fastest-growing segment of the population in industrialized nations is individuals
life expectancy was 49 years. over the age of 85, called the oldest old.35 Individuals in this age group tend to have
more activity limitations, experience more chronic conditions, and require more ser-
vices than younger adults. This oldest old population accounts for a large part of the
public health budget. Keeping older adults healthy will benefit not only the aging in-
dividuals themselves but also the family members who must find the time and resources
to care for them and the public health programs that attempt to meet their needs.
Good nutrition can prolong our healthy years Although nutri-

tion is not the key to immortality, a healthy diet can prevent malnutrition and delay
the onset of chronic disease. The diseases that are the major causes of disability in
older adults—cardiovascular disease, hypertension, diabetes, cancer, and osteoporo-
sis—are all nutrition-related. Exercise and a lifetime of healthy eating will not neces-
sarily prevent these diseases, but they may slow the changes that accumulate over time,
postponing the onset of disease symptoms. For example, the risk of developing cardio-
vascular disease can be decreased by exercise and a diet low in cholesterol, trans fat,
and saturated fat and high in whole grains, fruits, and vegetables. The risk of osteo-
porosis may be reduced by adequate calcium intake and an active lifestyle. And the
Okinawa, a series of islands between likelihood of developing certain types of cancer can be reduced by consuming a diet
mainland Japan and Taiwan, enjoys low in fat and high in whole grains, vegetables, and fruits.
the longest life expectancy in the
world (81.2 years), and has the
Aging affects recommendations
lowest rates of heart disease, cancer,
for some nutrients
and stroke which means the islands’
inhabitants also have the world’s The physiological and health changes that accompany aging affect the requirements
longest healthy life expectancy. for some nutrients, how nutrient requirements must be met, and the risk of malnutri-
Factors that are thought to contribute tion (Figure 13.18). In order to best recommend nutrient intakes for adults, the DRIs
to this long, healthy life are the include four adult age categories: young adulthood, ages 19 through 30; middle age,
practice of eating only until you are 31 through 50 years; adulthood, ages 51 through 70; and older adults, those over 70
80% full, an active lifestyle, a low- years of age. Recommendations are developed to meet the needs of the majority of
stress environment, and a moderate healthy individuals in each age group. Although the incidence of chronic diseases and
diet that is high in soy, vegetables, disabilities increases with advancing age, these are not considered when making gen-
and fish and low in salt and alcohol. eral nutrient intake recommendations.
Vitamin A
Vitamin D† 100%
Vitamin E
Vitamin K Men
Vitamin C Women
Thiamin
Riboflavin
Niacin
Vitamin B6
Folate FIGURE 13.18
Vitamin B12
The nutrient needs of older adults are not
Calcium drastically different from those of young
Magnesium adults. This graph illustrates the percentage
increase in micronutrient recommendations
Iron
for adults age 51 and older compared to
Iodine those of young adults ages 19 through 30.
Zinc The RDA for vitamin B12 is not increased,
0 10 20 30 40 50 but it is recommended that vitamin B12 be
Percent increase obtained from fortified foods or supplements.
†This represents the AI for individuals 51 to 70 years old. For those over age 70 the AI is The RDA for iron for women over 50 years
increased by 200% of age is reduced by 50%.
Energy needs are reduced in the elderly Energy needs generally

decrease with age in adults. Some of this decline is related to a decrease in lean body
mass, which reduces basal metabolism and therefore total energy requirements (Figure
13.19). For example, the EER for an 80-year-old man is almost 600 Calories per day
less than that for a 20-year-old man of the same height, weight, and physical activity A healthy diet won’t actually
level. For women, the difference in EER between an 80-year-old and a 20-year-old of keep you young but it can help
the same height, weight, and physical activity level is about 400 Calories per day.4 The
decrease in energy needs with age is even greater if activity level declines. Some of this
keep you fit and healthy for
decrease can therefore be prevented by maintaining an active lifestyle. more of your years.
Even though energy needs decline with age, some older adults don’t consume
enough to maintain a healthy body weight. People tend to gain weight in their 20’s,
30’s, and 40’s, but after age 65, it is more common for people to lose weight. Even in
50
Body Body
fat Body fat Body
fat fat
40
Percent of body weight
30
Muscle
Muscle
20
Muscle
Muscle
10
FIGURE 13.19
0 In most individuals, the proportion of muscle mass decreases and body fat increases
20 – 29 40 – 49 60 – 69 70 – 79 with age. (Adapted from Cohen, S. H., et al. Compartmental body composition based
Age group (years) on the body nitrogen, potassium, and calcium. Am. J. Physiol. 239:192–200, 1980)
older adults who are overweight, the risks associated with excess body fat are lower
than they are for younger adults.36 Stable body weight is a sign of good health. Weight
loss may reduce the ability to ward off disease or be a symptom of disease. Extreme
thinness or unintentional weight loss is a health risk, especially among older adults.
Although laboratory studies in animals have found that a diet deficient in energy can
Research on monkeys, rodents, slow aging and extend life span, this effect has not been demonstrated in humans.37
fish, and even fruit flies has
demonstrated that cutting calorie Recommendations for protein, carbohydrate and fat do
intake below normal increases not change with age Unlike calorie needs, the need for protein does not
longevity. The calorie-deprived decline with age. Therefore, an adequate diet for older adults must be somewhat
animals are also healthier, with higher in protein relative to calorie intake in order to meet needs.
more youthful hormone levels, The proportion of carbohydrate recommended in the adult diet also remains the
better immune function, and fewer same in older adults, but nutrient density becomes more important. Most dietary car-
chronic diseases. We don’t know bohydrates should be from less refined sources in order to ensure adequate vitamin
yet whether the same is true for and mineral intake despite a reduction in calorie needs. In addition, whole grains are
humans, but a national research higher in fiber. Fiber, when consumed with adequate fluid, helps prevent constipation,
project funded by the National hemorrhoids, and diverticulosis—conditions that are common in older adults. High-
Institute on Aging is currently fiber diets may also be beneficial in the prevention and management of diabetes, car-
underway to see if eating less can diovascular disease, and obesity.
also slow down aging in people. The digestion and absorption of fat does not change as adults age; therefore the
recommendations regarding dietary fat apply to older as well as younger adults. A diet
with 20 to 35% of energy from fat that contains adequate amounts of the essential
fatty acids and limits saturated fat, trans fat, and cholesterol is recommended. Follow-
ing these recommendations will allow older adults to meet their nutrient needs with-
out exceeding their energy requirements and may delay the onset of chronic disease.
However, there are certain situations, such as being underweight, where greater fat in-
take may be warranted.
Fluid intake is a concern in older adults The recommended water

intake for older adults is the same as that for younger adults; but meeting these needs
may be more challenging. With age there is a reduction in the sense of thirst, which
can decrease fluid intake.7 Changes in mobility may limit access to water even in the
presence of thirst. In addition, the kidneys are no longer as efficient at conserving
water, so water loss increases. Depression, which decreases water intake, and medica-
tions that increase water loss, such as laxatives and diuretics, also increase the risk of
dehydration in the elderly. Inadequate fluid intake along with low-fiber intake and
lack of activity increase problems with constipation.
Older adults should consume supplemental sources of

vitamin B12 The RDA for vitamin B12 is not increased for older adults, but it is
recommended that individuals over the age of 50 meet their RDA for vitamin B12 by
consuming foods fortified with the vitamin, such as breakfast cereals or soy-based
products, or by taking a supplement containing vitamin B12. This is because food-
▲* Atrophic gastritis An inflammation bound vitamin B12 is not absorbed efficiently in many older adults due to atrophic
of the stomach lining that causes a gastritis, an inflammation of the stomach lining accompanied by a decrease in the se-
reduction in stomach acid and allows cretion of stomach acid.38,39 It is estimated that 10 to 30% of American adults over
bacterial overgrowth. age 50 and 40% of those in their 80’s have atrophic gastritis. The vitamin B12 in forti-
fied foods and supplements is not bound to proteins, so it is absorbed even when
* Remember
Vitamin B12 that is found naturally in
stomach acid is low. Atrophic gastritis may also reduce the absorption of iron, folate,
calcium, and vitamin K. Reduced stomach acid secretion also allows microbial over-
foods is bound to food proteins. Chapter 8 growth in the stomach and small intestine. This increased population of microbes in
discussed how acid and protein digesting the gut further reduces vitamin B12 absorption by competing for available vitamin B12.
enzymes in the stomach release it from
food proteins so it can bind to intrinsic Reduced absorption and low intakes of calcium affect
factor, which is essential for adequate bone health Calcium status is a problem in the elderly because intakes are low
for absorption. and intestinal absorption decreases with age. Without sufficient calcium, bone mass
decreases and the risk of bone fractures increases. The loss of calcium from bone is ac-
celerated in women due to the normal hormonal changes of menopause. During ▲* Menopause Physiological changes
menopause, which normally occurs around the age of 50, the cyclical release of the fe- that mark the end of a woman’s capacity
male hormones estrogen and progesterone slows and eventually stops, causing ovula- to bear children.
tion and menstruation to cease. The decrease in estrogen is accompanied by changes
in mood, skin, and body composition, with body fat increasing and lean tissue de-
creasing. Reduced estrogen also increases the risk of osteoporosis by increasing the rate
of bone breakdown and decreasing calcium absorption from the intestine. As a result
of age-related bone loss the AI for adults over age 51 is 1200 mg, 200 mg greater than
the AI set for younger adults. Although the decrease in estrogen that occurs at
menopause causes bone loss, it cannot be prevented by increasing calcium intake
alone, so the recommended intakes for men and women are not different.
Vitamin D is a concern because intake is low and skin

synthesis is decreased Vitamin D is necessary for adequate calcium ab-
sorption, so a deficiency may contribute to bone loss. Vitamin D status is a concern in
the elderly for a number of reasons. First, intakes are often low, usually due to limited
consumption of dairy products. In addition, vitamin D synthesis in the skin is re-
duced due to limited exposure to sunlight, which is necessary for the formation of FIGURE 13.20
provitamin D, and because the capacity to synthesize provitamin D in the skin and to
form active vitamin D in the kidneys decrease with age (Figure 13.20). Using bone Sun exposure is often limited in the elderly
loss as an indicator of adequacy, the AI for men and women 51 to 70 years has been because they spend less time outdoors or
set at 10 g per day—twice as much as that of younger age groups. For individuals tend to wear clothing that covers or shades
over age 70, this is further increased to 15 g per day. their skin when they go out. (Tom Stewart/
Corbis Images)
A diet high in antioxidant nutrients helps prevent

chronic disease Antioxidant nutrients will not keep you young, but adequate
intakes may reduce the incidence of disease. Antioxidants, including vitamin E, vita-
min C, and -carotene, have been found to improve immune function and may
therefore help protect the body from infectious disease. Diets high in antioxidants
have also been associated with a reduced risk of heart disease and certain types of can-
cer. Oxidative damage is believed to cause two of the most common causes of visual
disorders in older adults, macular degeneration and cataracts. Macular degeneration is ▲* Macular degeneration Degeneration
the most common cause of blindness in older Americans. The macula is a small area of a portion of the retina that results in a
of the retina of the eye that distinguishes fine detail. If the number of viable cells in loss of visual detail and blindness.
the macula is reduced, visual acuity declines, ultimately resulting in blindness.
Cataracts are cloudy spots on the lens and sometimes the cornea, which obscure vision ▲* Cataracts A disease of the eye that
(Figure 13.21). Of people who live to age 85, half will have cataracts that impair vi- results in cloudy spots on the lens (and
sion. A diet high in foods containing antioxidant nutrients might slow or prevent sometimes the cornea), which obscure vision.
these eye disorders.40
But, don’t run to the supplement counter just yet. The evidence that antioxidants
in supplement form will prevent many of these chronic diseases is not as strong as the
evidence supporting a diet plentiful in foods high in these nutrients. When these nu-
trients are obtained from foods, they bring with them phytochemicals, some of which
offer additional antioxidant protection and some of which protect us from chronic
disease in other ways.
Supplements of lutein, an
antioxidant phytochemical found in
dark green leafy vegetables, have
been found to delay the onset of
macular degeneration and possibly
reverse some of the symptoms. You
FIGURE 13.21 can get your lutein in a pill or eat
3 to 4 ounces of spinach, which
Cataracts cause the lens of the eye to become cloudy and impair provides the amount found in most
vision. (© Science VU/Visuals Unlimited) supplements.
Consume plenty of fluids and fiber

• Drink a beverage with every meal
• Keep a bottle of water handy to sip on
• Use whole wheat bread
• Bake bran muffins
Pay attention to B12, calcium, and vitamin D
• Make sure your cereal is fortified with vitamin B12
• Drink milk; it gives you both calcium and vitamin D
• Sit in the sun to get some vitamin D with no calories at all
• Add some canned salmon to a salad for lunch
• Have yogurt for dessert
Antioxidize
• Have a bowl of strawberries
• Choose colorful vegetables to boost carotenoids
• Use vegetable oils in cooking to supply vitamin E
• Eat some nuts but not too many—they are high in calories
Work on your meals for one
• Ask the grocer to break up larger packages of eggs and meats
• Buy in bulk and share with a friend
• Make a whole pot but freeze it in meal-size portions
• Top a baked potato with leftover vegetables or sauces
The physical, mental, and social changes

of aging increase nutritional risks
The aging process itself is usually not a cause of malnutrition in healthy active
adults, but nutritional health can be compromised by the physical changes that
occur with age, the presence of disease, and economic, psychological, and social cir-
cumstances41 (Table 13.3). These can increase the risk of malnutrition by altering
nutrient needs and decreasing the motivation to eat and the ability to acquire and
enjoy food.
A decline in muscle strength leads to frailty With age there is a

decline in muscle size and strength. It affects both the skeletal muscles needed to move
the body and the heart and respiratory muscles needed to deliver oxygen to the tissues
(Figure 13.22). Therefore, both strength and endurance are decreased, making the
FIGURE 13.22
With age total muscle mass declines, leading to a loss of strength. These
magnetic resonance images of thigh cross-sections from a 25-year-old man
(left) and a 65-year-old man (right) illustrate that the older man has a
greater amount of fat (shown in white) around and through the muscle,
indicating significant muscle loss. (Courtesy S. A. Jubias and K. E. Conley,
University of Washington Medical Center)
TABLE 13.3
Aging Can Affect Nutrition
Organ or Process How It Changes How It Affects Nutrition and Health

Sensory Organs Ability to taste and smell declines. Reduces food intake by decreasing the
appeal and enjoyment of food.
Vision typically declines, often due to Reduces food choices by making shopping
macular degeneration or cataracts. for and preparation of food difficult.
Mouth Secretion of saliva decreases. Decreases the appeal of food by causing
dryness, which decreases the taste of food
and makes swallowing difficult. Increases
the likelihood of tooth decay and gum
disease because saliva is needed to wash
material away from the teeth and kill
bacteria.
Stomach Stomach emptying is slower and Reduces hunger and, therefore, nutrient
gastric secretions are reduced. intake. Reduced gastric secretions can
affect the absorption of some nutrients.
Colon Motility and elasticity are reduced, Increases the likelihood of constipation.
abdominal and pelvic muscles are
weakened, and sensory perception is
decreased.
Liver Liver size and blood flow are decreased Decreases the liver’s ability to metabolize
and fat accumulation increases. nutrients and break down drugs and
alcohol.
Pancreas Responsiveness to blood glucose levels Increases blood glucose.
decreases and the body cells may become
more resistant to insulin, resulting in
diabetes.
Kidneys Kidneys shrink and their ability to filter Increases blood urea levels when protein
blood and to excrete the products of intake is high. Increases the risk of
protein breakdown declines. The ability dehydration, which is made worse by a
to concentrate urine decreases. decline in the sensation of thirst with age.
Body Composition Body fat increases, especially in the Decreases in strength and endurance.
abdomen. Lean tissue, including muscle An increased risk of falls and fractures
and bone mass, decreases. due to weakness and a loss of bone mass.
Hormones Levels of growth hormone, DHEA Decreases in muscle and bone mass,
(dehydroepiandosterone), melatonin, changes in body rhythms, and immune
estrogen, and testosterone all decline. function.
Immune System Ability to fight disease declines. Increases the incidence of infections, cancers,
and autoimmune diseases, and decreases
the effectiveness of immunizations.
tasks of day-to-day life more difficult. The changes in muscle strength contribute not
only to physical frailty, which is characterized by general weakness, impaired mobility
and balance, and poor endurance, but also to the risk of falls and fractures. In the old-
est old, loss of muscle strength becomes the limiting factor determining whether they
can continue to live independently. The changes that occur with
Some of the reduction in muscle strength and mass is due to changes in hormone aging including an increase in
levels and in muscle protein synthesis, but a lack of exercise is also an important con- the prevalence of disease and
tributor.42 Regular exercise can help maintain muscle mass, bone strength, and car- the likelihood of social and
diorespiratory function and can increase energy needs. Exercise can reduce the loss of economic changes, increase
lean body mass, maintain fitness and independence, and allow an increase in food the risk of malnutrition.
intake without weight gain so micronutrient needs are more easily met. Therefore,
maintaining regular physical activity remains important throughout life.
Medical conditions can limit the ability to meet nutrient

needs More than half of the older population suffers from some form of physical
illness or disability, and the incidence increases with advancing age. These limitations
affect the ability to maintain good nutritional health by changing nutrient require-
ments, decreasing the appeal of food, and impairing the ability to obtain and prepare
an adequate diet.
Some illnesses change nutrient recommendations. For instance, kidney failure re-
duces the ability to excrete protein waste products. Therefore, the diet has to be lim-
ited in protein. Blood pressure is affected by sodium intake so a low sodium diet is
recommended for those with high blood pressure. Dietary restrictions such as these
limit food choices and can affect the palatability of the diet. These dietary restrictions
may contribute to malnutrition if the elderly individuals and their families are not
provided with enough information about how to substitute foods that will provide ad-
equate energy, nutrients, and eating pleasure.
Physical disabilities can limit the ability to obtain and prepare food and therefore
reduce food intake and increase the risk of malnutrition. The most common cause of
▲* Arthritis A disease characterized physical disability among older adults is arthritis, a condition that causes pain upon
by inflammation of the joints, pain, and movement. Osteoarthritis is a type of arthritis that affects over 33 million Ameri-
sometimes changes in structure. cans.43 It occurs when the cartilage that prevents the bones in joints from rubbing to-
gether degenerates over time, causing pain. Arthritis is treated with drugs that reduce
inflammation, such as aspirin and ibuprofen, and with pain relievers such as aceta-
minophen. Supplements containing glucosamine and chondroitin sulfate are also used
by arthritis sufferers. Glucosamine and chondroitin sulfate are not essential nutrients.
But in the body, they are needed for the synthesis of large molecules that bind water
to form a porous, gel-like material that allows cartilage to resist crushing forces and
cushion the joints. It has been suggested that when consumed in the diet, glucosamine
and chondroitin sulfate provide the raw materials needed to synthesize these large
cushioning molecules. Glucosamine may also inhibit inflammation and increase the
production of a compound that contributes to the lubricating and shock-absorbing
properties of cartilage. Supplements of both glucosamine and chondroitin sulfate are
said to reduce arthritis pain, stop cartilage degeneration, and possibly stimulate the re-
pair of damaged joint cartilage. Results of studies of the effectiveness of these supple-
ments have been mixed but the National Institutes of Health (NIH) is currently
conducting a large trial in centers across the country to evaluate the effects of glu-
cosamine and chondroitin sulfate, given separately and in combination, for reducing
pain and improving function in patients with osteoarthritis of the knee.44
Mental changes can affect nutritional status Mental changes

▲
* Dementia A deterioration of mental in the elderly may be due to depression or to dementia. Regardless of the cause, these
state resulting in impaired memory, thinking, mental problems can affect the ability to consume a healthy diet.
and/or judgment. Depression in the elderly may be caused by social, psychological, and physical fac-
tors. For example, retirement and the death or relocation of friends and family can
For more information on cause social isolation, which contributes to depression. The inability to engage in nor-
Alzheimer’s go to the mal daily activities, visit with friends and family easily, and provide for personal needs
Alzheimer’s Disease also contributes to depression as does the loneliness of living, cooking, and eating by
Education and Referral oneself. Depression can make meals less appetizing and decrease the quantity and
Center at the National quality of foods consumed, thereby increasing the risk of malnutrition.
Institute on Aging at Many individuals maintain adequate nervous system function into old age, but the
www.alzheimers.org or the Alzheimer’s incidence of dementia does increase with age. Dementia involves an impairment in
Association at www.alz.org memory, thinking, or judgment that is severe enough to cause personality changes and
affect daily activities and relationships with others. It may be caused by multiple
▲* Alzheimer’s disease A disease that strokes, alcoholism, vitamin B12 deficiency, or Alzheimer’s disease. Alzheimer’s disease
results in the relentless and irreversible is the cause of over half of the cases of dementia in the elderly. It involves a progres-
loss of mental function. sive, incurable loss of mental function. The brains of patients with Alzheimer’s disease
are characterized by the accumulation of an abnormal protein in the spaces between

nerve cells and tangled protein fibers inside the nerve cells. Together these block the
normal passage of electrical signals between nerve cells that allow us to think, talk, re-
member, and move. As the disease progresses nerve cells die, the brain shrinks, and
function deteriorates. Its cause is unknown, but there does appear to be a genetic
component in some cases. Drugs can treat some of the symptoms, but there is no cure When high aluminum levels were
and it is eventually fatal. Many ineffective nutritional cures have been marketed for discovered in the brains of
Alzheimer’s disease. Supplements of choline and lecithin have been promoted to in- Alzheimer’s patients, many people
crease levels of the neurotransmitter acetylcholine, which is deficient in Alzheimer’s tried to reduce exposure by
patients, and antioxidant supplements have been suggested to prevent free radical throwing out their aluminum pans
damage. To date, there is little evidence that nutritional supplements are helpful in and not using aluminum-containing
treating or preventing Alzheimer’s disease. deodorants. Unfortunately, there is
little evidence that this is beneficial
Increased use of medications can affect nutritional sta- because Alzheimer’s has not been
tus The medications required to treat the diseases that become more common with linked to high dietary or
age can also affect nutritional status. Almost half of older Americans take multiple environmental aluminum.
medications daily (Figure 13.23).45 The more medications taken, the greater the
chance of side effects that affect nutritional status such as increased or decreased ap-
petite, changes in taste, constipation, weakness, drowsiness, diarrhea, and nausea.
Complications related to incorrect doses or inappropriate combinations of medica-
tions are also a significant problem in the elderly. Medications can affect nutritional
status and nutritional status can alter the effectiveness of drugs. This is true whether
the medication is a prescription drug, an over-the-counter medication, or a dietary
supplement.
Medications can alter nutrient intake, absorption, me-

tabolism, and excretion Medications can affect nutritional status by alter-
ing appetite, nutrient absorption, metabolism, or excretion (Table 13.4). For example,
more than 250 drugs, including blood pressure medications, antidepressants, decon-
gestants, and the pain reliever ibuprofen (found in Advil, Motrin, and Nuprin), can
cause mouth dryness, which can decrease interest in eating by interfering with taste,
chewing, and swallowing. Mineral oil laxatives and cholestyramine (Questran), which
is used to reduce blood cholesterol, can decrease the absorption of fat-soluble vitamins
and some types of diuretics can increase the excretion of potassium from the body.
These effects have the greatest nutritional impact on individuals who must take med-
ications for extended periods, those who take multiple medications, and those who al-
ready have marginal nutritional status.
Food and nutritional status affect how well medications

work Food components can either enhance or retard the absorption and metabo-
lism of drugs. Some medications are absorbed better or faster if taken with food
whereas others are absorbed faster if taken with just water. Some, such as aspirin and
ibuprofen, should be taken with food because they are irritating to the gastrointestinal FIGURE 13.23
tract. Drugs may also interact with specific nutrients. For instance, the antibiotic
tetracycline should not be taken with milk because it binds with calcium, making Most older adults take one or more medications
both unavailable. every day. (Michael Newman/PhotoEdit)
Nutritional status can also affect drug metabolism. If nutritional status is poor, the
body’s ability to detoxify drugs may be altered. For example, in a malnourished indi-
vidual, theophylline, used to treat asthma, is metabolized slowly, resulting in high
blood levels of the drug, which can cause loss of appetite, nausea, and vomiting.
Specific nutrients can also affect the metabolism of drugs. High-protein diets en-
hance drug metabolism in general, and low-protein diets slow it. Vitamin K hinders
the action of anticoagulants, taken to reduce the risk of blood clots. On the other
hand, omega-3 fatty acids, such as those in fish oils, inhibit blood clotting and may
intensify the effect of an anticoagulant drug and cause bleeding. It is safe to eat fish
while taking anticoagulant drugs; however, the use of fish oil supplements is not rec-
ommended. Drugs can also interact with each other. For example, ibuprofen interferes
TABLE 13.4
Medications May Cause Nutritional Deficiencies
Drug What It Does Possible Nutritional Problems

Digoxin Stimulates the heart GI upset, loss of appetite, and nausea
Codeine Relieves pain Constipation, nausea, and vomiting
Aspirin Relieves pain, reduces heart Stomach irritation, small amounts of painless
attack risk bleeding in the gastrointestinal tract can
result in iron loss
Antacids that contain aluminum Relieve heartburn Combine with phosphorus in the gut to form
or magnesium hydroxide compounds that cannot be absorbed; chronic
(Rolaids or Maalox) use can result in loss of phosphorus from bone
Stimulant laxatives (Ex-lax, Relieve constipation Deplete calcium and potassium, cause
Senna, Milk of Magnesia) electrolyte imbalance and dehydration
Coumadin Prevents blood clots Inhibits vitamin K activity
Diuretics Reduce blood pressure and blood Some types (thiazides) increase potassium
volume by increasing water loss excretion
with the properties of aspirin that help prevent heart disease. Individuals taking any
medication should consult their doctor, pharmacist, or dietitian regarding how the
drug could affect the action of other drugs they may be taking, how the drug could af-
fect their nutrition, and how their nutrition could affect the action of the drug.
The DETERMINE checklist helps assess the risk

of malnutrition
The physical, mental, social, and economic changes that accompany aging all increase
the risk of malnutrition. When malnutrition occurs in the elderly, it begins a downward
spiral from which it is difficult to recover. Poor nutritional health decreases immune
function, which increases the incidence of disease, which worsens malnutrition by in-
creasing nutrient and energy requirements and decreasing intake (Figure 13.24). To ad-
dress concerns over the nutritional health of the elderly, the federal Nutrition Screening
Initiative was developed to promote screening for and intervention in nutrition-related
problems in older adults.46 This program is working to increase the awareness of nutri-
tional problems in the elderly by involving practitioners and community organizations
MALNUTRITION
Decreased Decreased nutrient intake Decreased

immune Increased nutrient need muscle
function mass
Increased use
of medications
Increased Decreased
illness accessibility
of food
FIGURE 13.24
The causes and consequences of malnutrition in the elderly are linked.
TABLE 13.5
DETERMINE: A Checklist of the Warning Signs of Malnutrition
Disease Any disease, illness, or condition that causes

changes in eating can predispose one to
malnutrition. Memory loss and depression can also
interfere with nutrition if they affect food intake.
Eating poorly Eating either too little or too much can lead to
poor health.
Tooth loss/mouth pain When the mouth, teeth, and gums are not
healthy it interferes with the ability to eat.
Economic hardship Having to, or choosing to spend less than
$25–$30 per person per week on food interferes
with nutrient intake.
Reduced social support Not being with people on a daily basis has a
negative effect on morale, well-being, and eating.
Multiple medicines The more medicines one takes, the greater the
chances of side effects such as weakness,
drowsiness, diarrhea, changes in taste and
appetite, nausea, and constipation.
Involuntary weight loss/gain Unintentionally losing or gaining weight is a
warning sign that should not be ignored. Being
overweight or underweight also increases the
risk of malnutrition.
Needs assistance in self-care Difficulty walking, shopping, and cooking
increases the risk of malnutrition.
Elder above age 80 The risks of frailty and health problems increase
with increasing age.
as well as relatives, friends, and others caring for the elderly in evaluating the nutritional
status of the aging population. This program developed the DETERMINE checklist,
which is based on an acronym for the physiological, medical, and socio-economic situa-
tions that increase the risk of malnutrition among the elderly (Table 13.5). The elderly
themselves, family members, and caregivers can use this tool to identify when malnutri-
tion is a potential problem.
Meeting nutritional needs involves nutritional,

social, and economic considerations
Despite the fact that the nutrient needs of older adults are not drastically different For public health
from those of young adults, it is more challenging to meet these needs. One reason for data and statistical
this is that energy needs are reduced while most micronutrient needs remain the same information on older
or increase. Therefore the nutrient density of the diet must be high. In some cases, nu- adults, go to the
trient supplements may be necessary to meet needs. Other reasons are related to the National Center for
medical, social, and economic challenges that often accompany aging. Health Statistics at www.cdc.gov/nchs/
A modified Food Guide Pyramid helps plan diets for the

elderly A modified Food Guide Pyramid has been developed to emphasize the nu-
trients and food selections that are of particular concern for older adults (Figure
13.25). This pyramid is built on a base of water—eight 8-ounce glasses per day. This
helps emphasize that dehydration is a common problem and that older adults need to
be more conscious of water consumption. This pyramid also has a narrower base than
the traditional USDA Food Guide Pyramid to illustrate that energy needs are typically
Calcium, Vitamin D,
Vitamin B12
Supplements
Fat, Oils, & Sweets

Use sparingly
Milk, Yogurt, f+ Meat, Poultry, Fish, Dry

& Cheese Group Beans, Eggs, & Nut Group
3 Servings 2 or more Servings
f+
f+ f+
Vegetable
Fruit Group
Group
2 or more Servings
3 or more
Servings f+ f+
f+ f+ f+
Bread, Fortified
Cereal, Rice, &
Pasta Group
6 or more Servings
f+ f+ f+
f+
Water
8 or more Servings
FIGURE 13.25
H2O H2O H2O H2O H2O H2O H2O H2O
This modification of the Food Guide Pyramid
targets the needs of healthy mobile seniors fat (naturally occurring and added)
(over age 70) and is not designed to meet the sugars (added)
needs of those with special dietary needs or f+ fiber (should be present)
significant health problems. These symbols show fat, added sugars, and fiber in foods.
reduced among the elderly.47 The recommended numbers of servings are equal to or
greater than the minimums recommended by the Food Guide Pyramid, and nutrient-
dense choices from each food group are recommended. To highlight the importance
of fiber in the diets of older adults, the pyramid for seniors includes a fiber icon in the
food groups containing high-fiber foods such as grains, fruits, vegetables, and beans,
nuts, and seeds. Another key difference in this pyramid is a flag at the top that indi-
cates the possible need for dietary supplements.
Dietary supplements may be necessary to meet the

needs of older adults Many older adults may benefit from vitamin D sup-
plements because production of this vitamin in the skin is decreased and exposure to
sunlight may be limited. A calcium supplement may be necessary to meet needs, par-
ticularly in elderly women because it can be difficult to consume 1200 mg of calcium
from food without exceeding energy needs. Supplemental vitamin B12 from pills or
fortified foods is recommended for older adults because the absorption of vitamin
B12 decreases with age. However, supplements should not take the place of a balanced,
nutrient-dense diet high in whole grains, fruits, and vegetables. These foods also con-
tain phytochemicals and other substances that may protect against disease.
A multivitamin and mineral supplement containing no more than 100% of the
Daily Value for any nutrient is the safest way to supplement the diet. Supplements
PIECE IT TOGETHER
Is She at Risk of Malnutrition?

Shirley is 82 years old. She lives alone in the city. Recently, her Food Amount
teeth were extracted because of periodontal disease. As a result of Dinner
her dental problems, she has eaten only cottage cheese and milk Low-fat milk 1 cup
for the past week. Even though she is now feeling better, her Instant rice 1 cup
granddaughter, Anna, begins to worry about Shirley’s nutrition. Beef 3 oz
Anna decides to review the DETERMINE checklist with her Peas 1 cup
grandmother to see if she is at risk of malnutrition.
Total energy (Cal) 1035
Checklist Grandma Shirley
H OW DOES S HIRLEY ’ S DIET COMPARE
Disease She has high blood pressure,
TO THE RECOMMENDATIONS OF THE
arthritis, periodontal disease,
F OOD G UIDE P YRAMID FOR PEOPLE OVER 70?
and cataracts.
Eating poorly She has only eaten cottage ▼
cheese and milk for a week; • The bran flakes she has for breakfast are a good source
she doesn’t like to cook for of fiber but are not fortified with vitamin B12, a
herself. vitamin that is poorly absorbed from food in many
Tooth loss or mouth pain Yes. older adults.
Economic hardship None. • She consumes only about 4 cups of fluid. Even with
Reduced social support Anna visits regularly but the additional fluid provided by foods her intake is well
Shirley has few friends. below the 2.7 liters recommended by the DRIs, which
Multiple medicines She takes blood pressure may put her at risk of dehydration
and arthritis medications. • Your answers:
Involuntary weight loss/gain She thinks she has lost about
10 pounds since her dental
problems began.
Needs assistance in self-care She needs help shopping S UGGEST FOODS S HIRLEY COULD
and cleaning. ADD TO IMPROVE HER DIET WITHOUT
Elder above age 80 She is 82 years old. INCREASING THE TIME SHE SPENDS COOKING
▼
Eight of the items on the DETERMINE checklist apply to
Anna’s grandmother, confirming her concerns about the risk Your answer:
of malnutrition. Anna takes Shirley to a dietitian who asks
her to recall the diet she ate before her teeth were extracted.
W HATOTHER FACTORS NEED TO BE CONSIDERED
Shirley’s Original Diet WHEN RECOMMENDING A DIET FOR S HIRLEY ?
Food Amount ▼
Breakfast Shirley needs a diet that includes foods that are not only
Bran flakes 3/4 cup easy to prepare and carry home on the bus but that are also
Low-fat milk 1 cup easy to chew. To ensure her grandmother has the foods she
Coffee 1 cup needs to stay healthy Anna decides to take Shirley shopping
Low-fat milk 1 Tbsp once a month for the heavy, bulky items like paper goods,
Sugar 2 tsp laundry soap, rice, cereal, and canned foods. Shirley can
Lunch handle the smaller, more perishable items when she takes
Chicken soup 1 cup the bus to the store.
Crackers 6 pieces
Apple 1 small
TABLE 13.6
Can a Supplement Help?
Supplement What It Claims To Do Actual Benefit or Risk

Lecithin Lower cholesterol and treat No proof that it does either.
Alzheimer’s disease
RNA Rejuvenate old cells, improve memory, No controlled studies to support any
and prevent wrinkling of these claims.
Superoxide dismutase (SOD) Protect against oxidative damage, slow SOD is a protein that is broken down
aging, and treat Alzheimer’s disease to amino acids in the GI tract, so oral
supplements will not increase blood
or tissue levels of this enzyme.
Coenzyme Q Enhance immune function It does not boost immune function and may
pose a risk to people with poor circulation.
-carotene, zinc, vitamin E, Enhance immune function Supplements of -carotene and several
and vitamin B6 micronutrients, including zinc, vitamin E, and
vitamin B6, have been shown to improve
immune response but these individuals may
have been deficient in these nutrients prior
to supplementation. High doses of zinc,
copper, and iron, depress immune function.
DHEA Strengthen bones, muscles, and the DHEA is a precursor to the sex hormones
immune system, and prevent diabetes, testosterone, estrogen, and progesterone.
obesity, heart disease, and cancer Beneficial effects of DHEA supplementation
have not been clearly established in humans.
The increases in sex hormones that may
occur with DHEA administration could
increase the risk of certain types of cancer.
Melatonin Slow aging, antioxidant that Melatonin is a hormone that is secreted by
enhances immune function the pineal gland. It is involved in regulating
the body’s cycles of sleep and wakefulness.
Melatonin is an antioxidant but an antiaging
effect in humans has not been determined.
Glucosamine and chondroitin Relieve pain of osteoarthritis and Glucosamine plays a role in cartilage
sulfate slow cartilage damage formation and repair. Chondroitin sulfate
is part of a large protein molecule
(proteoglycan) that gives cartilage elasticity.
Both are found in the body and there is
evidence that supplements may help
relieve symptoms of arthritis.
containing megadoses should be avoided. Supplements of most nonnutrient substances

provide no proven benefit, many are costly, and others can be toxic (Table 13.6).
Modified food choices may be necessary to meet needs

Older adults with physical limitations need to choose foods that they can easily pre-
pare and consume. For some this may be as simple as selecting foods that are easily
chewed and digested. For example, a person with dentures may not be able to eat fresh
fruit and raw vegetables. But they can meet their needs by substituting canned, or soft
fruit and fruit juices for hard-to-chew fruits, and replacing raw vegetables with cooked
ones. Eggs and stewed meats can provide easy-to-chew protein sources. For those who
have difficulty preparing foods, precooked foods, frozen dinners, as well as instant
foods such as cereals, rice and noodle dishes, and soups that just require adding water,
can provide a meal with almost no preparation. Medical nutritional products such as
Ensure or Boost, can also be used to supplement intake. These canned, fortified prod-
ucts have a long shelf life and can meet nutrient needs with a small volume.
Economic and social issues must be considered to avoid

malnutrition Ensuring adequate nutrient intake may involve providing nutrient-
dense meals or providing education on nutrient needs, economics, and food prepara-
tion. Or, it may require providing assistance with shopping and food preparation. For
some, who can no longer care for themselves independently, assisted living or a nursing
home setting is required to meet needs.
Fixed incomes decrease the food budget To meet nutrient needs

older adults must have access to a healthy diet. This is a problem for the approxi-
mately 3.4 million elderly persons who live below the poverty level.48 After retirement
many older individuals, regardless of income level, must live on a fixed income, mak-
ing it difficult to afford health care, especially medications, and a healthy diet. Food is
often the most flexible expense in the budget, so limiting the types and amounts of
foods consumed may be the only option available for older adults trying to meet ex-
penses. Substandard housing and inadequate food preparation facilities can make the
situation worse because food cannot easily be prepared and eaten at home. Options
for people on limited incomes include reduced-cost meals at senior centers, food
stamps, food banks, soup kitchens, and commodity foods. Programs that provide edu-
cation about low-cost nutritious food choices can also help those with a limited bud-
get to meet nutrient needs.
Increasing social interaction can increase nutrient intake

Social isolation limits food intake. Eating out at senior centers or low-cost restaurants
or sharing shopping and cooking chores with a friend can help meet nutrient needs by
reducing cooking demand and increasing social interaction. Home health services can
help with cooking and eating, and most senior centers, health departments, or social
service agencies offer meals, rides, and in-home care.
Nutrition programs can help maintain nutritional health For information about
in the elderly The Federal Older Americans Act provides nutrition services to healthy aging and
older individuals who are in economic need, particularly low-income minorities. Pro- resources for elderly
grams that provide nutritious meals in communal settings promote social interaction persons and their
and can improve nutrient intake. The Congregate and Home-Delivered Nutrition families, go to the
Programs established by the Older Americans Act provide congregate meals at loca- Administration on Aging at
tions such as senior centers, community centers, schools, and churches. For those who www.aoa.dhhs.gov/, the National Institute
are unable to attend congregate meals, home-delivered meals are available. on Aging at www.nih.gov/nia/, or visit the
Although such programs are a first step in meeting nutritional needs, currently Meals on Wheels Association of America at
most provide only one meal a day for five days a week. Each meal served must provide www.projectmeal.org/
at least a third of the 1989 RDA. Oftentimes however, because seniors don’t have the
resources or ability to prepare other meals, these delivered meals end up providing al-
most half of their total intake for the day.49 Studies have shown that individuals who
receive these meals have a better-quality diet and fewer hospitalizations than those
who do not.50 These and other programs addressing the nutritional needs of older
adults are described in Table 13.7.
Assisted living has benefits and risks For many, the physical and
psychological decline associated with aging eventually causes them to require assis-
tance in living. Without help, many older adults may be unable to get to markets and
food programs, restricting the types of food available to them. While a social support
system consisting of family members, friends, and other caregivers can help many
people stay at home, others may require assisted-living facilities, where they have their
own apartments but can obtain assistance around the clock. For some, however, the
degenerative changes of disease and aging require a nursing home to provide the ap-
propriate care.
TABLE 13.7
What Federal Programs Help Older Americans?
Older Americans Act—Title III Congregate and Home-Delivered
Nutrition Programs
Serves at least one meal five days a week to persons 60 years and older. Meals
are served at home or in churches, schools, senior centers, or other facilities.
Older Americans Act—Title VI Congregate and Home-Delivered
Nutrition Programs
Provides home-delivered and congregate meals to Native American
organizations.
Older Americans Act—Title III Health Promotion and Disease
Prevention Program
Provides health-promotion and disease-prevention services in areas where there
are large numbers of economically needy older adults.
Nutrition Screening Initiative
Promotes nutritional screening and more attention to nutrition in all health-care
and social-service settings that provide for older adults.
Food Stamp Program
Provides food stamps to low-income individuals including the elderly. These can
be used instead of cash to purchase food.
Nutrition Program for the Elderly
Provides grants, cash, and commodity foods to states and tribes to supplement
congregate and home-delivered meal programs.
Commodity Supplemental Food Program—Elderly
Provides food, nutrition education, and health-service referrals to individuals
with low incomes, including the elderly.
Child and Adult Care Food Program (Adult Day Care)
Provides cash reimbursements and food commodities to community day-care
centers that serve meals and snacks to children and elderly with special needs.
Food Distribution Program on Indian Reservations
Distributes commodity foods to low-income persons, including the elderly, living
on or near Indian reservations.
Those in nursing homes are at increased risk for malnutrition because they are
more likely to have medical conditions that increase nutrient needs or that interfere
with food intake or nutrient absorption, and because they are dependent on others to
provide for their care. In addition, 50% of institutionalized elderly suffer from some
form of disorientation or confusion, which further increases the likelihood of de-
creased nutrient intake. Even when adequate meals are provided, nursing-home resi-
dents frequently do not consume all of the food served, increasing the likelihood of
fluid and energy deficits.51
Drinking Alcohol Can Be a Risk at All Stages of Life

Alcohol provides energy to the body, about 7 Calories per gram, but it is not consid-
ered a nutrient. It is a drug that is often harmful. When consumed by a pregnant
woman, alcohol can cause birth defects in the developing child. When consumed dur-
ing childhood and adolescence, when the brain is still developing and changing, alco-
hol can cause permanent reductions in learning and memory.52 Excessive long-term
alcohol use contributes to malnutrition and can cause permanent liver damage. Any-
one who regularly consumes alcohol is at risk of developing alcohol dependence,
Drinking Alcohol Can Be a Risk at All Stages of Life 481
known as alcoholism. Alcoholism is believed to have a genetic component that makes

some people more likely to become addicted, but lifestyle factors such as the influence
of your friends, the amount of stress in your life, and the availability of alcohol also
significantly affect your risk for alcoholism. Thus, someone with a genetic predisposi-
tion toward alcoholism whose peers do not consume alcohol is much less likely to be-
come addicted. Alcoholism, like any other drug addiction, is a physiological problem
that needs treatment. Despite the risks associated with alcohol use, it has been part of
almost every culture for centuries, and when consumed in moderation, may have
some beneficial health effects.
Alcohol enters the bloodstream quickly

Alcohol is a small molecule that is rapidly and almost completely absorbed in the
upper gastrointestinal tract. Because some alcohol is absorbed directly from the stom-
ach, its effects are almost immediate, especially when consumed on an empty stom-
ach. When consumed with food, less is absorbed from the stomach and absorption Some alcohol is broken down by an
from the intestines is slowed. Once it is absorbed, alcohol is broken down by enzymes enzyme in the stomach. Women
in the liver to form the same 2-carbon molecule that results from the breakdown of tend to have less of this stomach
carbohydrate, fat, and some amino acids (see Chapters 4, 5, and 6). This can be used enzyme, which may be one reason
to produce energy in the form of ATP but some of the by-products of alcohol metabo- women become intoxicated after
lism inhibit this, so much of it is used to synthesize fatty acids. consuming less alcohol than men.
The effects of alcohol depend on the amount consumed

In an average person, the liver can break down about one-half ounce of alcohol per
hour; this amount varies depending on the body size, amount of previous drinking,
food consumed, and general health of the drinker. When alcohol intake exceeds the
ability of the liver to break it down, the excess circulates in the bloodstream until the
liver enzymes can metabolize it. When it reaches the kidneys, alcohol acts as a di-
uretic, increasing fluid excretion. Therefore, excessive alcohol intake can cause dehy-
dration. At the brain, alcohol acts as a depressant. First it affects reasoning; if drinking
continues, the vision and speech centers of the brain are affected. Next, large-muscle
control becomes impaired, causing lack of coordination. Finally, the individual loses
consciousness. If drinking were to continue, the anesthetic effects would suppress
breathing and heart rate. It is possible for someone to drink fast enough that alcohol
levels continue to rise after he or she has lost consciousness, resulting in death. This
can occur with binge drinking—frequently downing five or more drinks at a time.
Binge drinking is a problem on college campuses; it is most common in people be-
tween the ages of 18 and 24 years.53
Breath alcohol can be used to estimate blood alcohol

levels Because some alcohol is eliminated by the lungs, breath alcohol can be used
to estimate blood alcohol levels. This is the basis of the Breathalyzer tests administered For more information
by the police to determine if an individual is driving under the influence of alcohol. on the health effects
The effects of alcohol on the central nervous system are what make driving while of alcohol go to the
under the influence of alcohol so dangerous. Alcohol affects reaction time, eye-hand National Institute
coordination, and balance. Not only does alcohol impair one’s ability to operate a of Alcohol Abuse and
motor vehicle, but it also impairs one’s judgment in the decision to drive. Alcoholism at www.niaaa.nih.gov
Long-term excessive alcohol consumption has

serious health consequences
Alcohol either directly or indirectly affects every organ in the body and increases the
risk of malnutrition and many chronic diseases. Alcohol contributes energy but few
other nutrients and replaces more nutrient-dense energy sources in the diet. Alcohol
damages the lining of the small intestine, decreasing the absorption of several B vita-
mins and vitamin C. Thiamin deficiency is a particular concern with chronic alcohol
consumption. Alcohol can also alter the storage, metabolism, and excretion of other
vitamins and some minerals. Moderate alcohol consumption can increase the risk of
(a) (b)
FIGURE 13.26
Chronic alcohol consumption can cause permanent liver damage. A normal liver is shown on the left (a), and a
cirrhotic liver is shown on the right (b). (a: Custom Medical Stock Photo, Inc. b: Science Herita/Custom Medical
Stock Photo)
obesity. Calories consumed as alcohol are more likely to be deposited as fat in the ab-
dominal region; excess abdominal fat increases the risk of high blood pressure, heart
disease, and diabetes. There is also some evidence suggesting that alcohol consump-
tion may increase the risk of breast and colon cancer; the effects depend on the
amount consumed.54
The most significant physiological effects of chronic alcohol consumption occur in
the liver. Alcoholic liver disease progresses in three phases. The first phase is fatty liver,
a condition that occurs when alcohol consumption increases the synthesis and deposi-
▲* Alcoholic hepatitis Inflammation of tion of fat in the liver. The second phase, alcoholic hepatitis, is an inflammation of the
the liver caused by alcohol consumption. liver. Both of these conditions are reversible if alcohol consumption is stopped and
good nutritional and health practices are followed. If alcohol consumption continues,
▲* Cirrhosis Chronic liver disease cirrhosis may develop. This is an irreversible condition in which fibrous deposits scar
characterized by the loss of functioning the liver and interfere with its function. Since the liver is the primary site of many
liver cells and the accumulation of fibrous metabolic reactions, cirrhosis is often fatal (Figure 13.26). In addition to causing liver
connective tissue. disease, heavy drinking is associated with hypertension, heart disease, and stroke.
There are benefits to moderate alcohol

consumption
Moderate alcohol consumption, defined as no more than one drink a day for women
and two drinks a day for men, may have benefits. Consuming alcoholic beverages be-
fore or with meals can stimulate appetite and improve mood. It can be relaxing, pro-
ducing a euphoria that can enhance social interactions. Studies have shown that light
drinking is associated with a reduction in mortality.55 Most of this effect is likely due
to the inverse relationship between heart disease and consumption of small amounts
of alcohol.56 Alcohol consumption increases HDL cholesterol level and may have an
effect on the formation of blood clots. These benefits are stronger when red wine is
consumed, likely due to the phytochemicals, called polyphenols, that it contains.57
Polyphenols, also found in red grape juice, have also been shown to reduce blood pres-
sure.58 The beneficial effects of red wine consumption have been suggested as a reason
for the lower incidence of heart disease in certain cultures. For example, the Mediter-
ranean diet, which has been associated with a reduced risk of heart disease, includes
daily consumption of wine in moderation. The French also consume a glass of wine
with meals and this is one explanation for the French paradox—the fact that the
French eat a diet that is as high or higher in fat than the American diet but suffer from
far less heart disease.
If you drink alcohol do so in moderation

Whether the benefits of alcohol consumption outweigh the risks, drinking is a per-
sonal decision that must consider lifestage and other factors. Some people should not
consume any alcohol. For instance, women who are pregnant or trying to conceive
Drinking Alcohol Can Be a Risk at All Stages of Life 483
should not consume alcohol because it can damage the fetus. Children and adoles-
cents should not consume alcohol because they are more likely to suffer its toxic ef-
fects—drunkenness and poisoning leading to seizures, coma, and death. Individuals
who plan to drive or operate machinery should not consume alcohol because it can
impair coordination and reflexes. Alcoholics should avoid alcohol because they cannot
restrict their drinking to moderate levels. Finally, individuals taking medications that
can interact with alcohol should avoid alcohol.
Individuals who do drink should not drink in excess (Figure 13.27). When alco-
hol is consumed, it should be consumed slowly with meals, which slows absorp-
tion. It usually takes an hour to metabolize the alcohol in one drink (0.5 ounces
distilled liquor, 12 ounces beer, or 5 ounces wine), so no more than one drink If you drink alcoholic
should be consumed every 1.5 hours. Sipping, not gulping, gives the liver time to beverages, do so in moderation
break down what has already been consumed. Unfortunately, once alcohol is in the
body, the rate at which it is metabolized and eliminated cannot be accelerated. FIGURE 13.27
Cold showers, brisk walks, and black coffee may wake you up, but they will not
sober you up. The Dietary Guidelines for Americans
recommends that alcohol be consumed in
moderation. (USDA, DHHS, 2000)
THINKING FOR YOURSELF
1. Do these height and weight measurements recorded for a b. What is the percent of calories from carbohydrate and
girl from age 6 to age 9 indicate any problems? fat in the meal?
c. Compare the amount of calories, fat, protein, iron,
Age Height (in.) Weight (lb)
calcium, and vitamin A to the recommended intake
6 45 44
for someone of your age, weight, and lifestage.
7 48 53
8 50 77 4. How does age affect energy needs?
9 52 97 a. How does your average energy intake from the food
record you kept in Chapter 2 compare to the EER for
a. Calculate her BMI and plot the values on a BMI-for-
a person who is your height, weight, and activity level
age growth chart (growth charts are in Appendix B).
but is 75 years old?
b. What recommendations would you have about her
b. Modify your food choices for one day to meet the
weight?
recommendations of the senior Pyramid shown in
2. What food groups are included in a fast-food lunch? Figure 13.25 while not exceeding what your energy
a. How many servings from each food group of the Food needs would be at age 75.
Guide Pyramid do a Big Mac, fries, and a 16-ounce
5. How do medical conditions and dietary restrictions affect
cola represent?
food choices?
b. If you ate this fast-food meal for lunch, how many
a. How might you modify your food choices to
additional servings from each food group would you
accommodate a low-sodium diet?
need to satisfy the daily recommendations of the Food
b. How might you modify your food choices to
Guide Pyramid?
accommodate a restriction of protein to 0.6 gram
c. Select foods from each group to complete your intake
per kilogram of body weight?
for the day.
c. How might you modify your food choices to
d. Do the foods you selected meet the selection
accommodate a loss of smell and taste?
recommendations of the Food Guide Pyramid
d. How might you modify your food choices to
(Table 2.1) and your energy needs?
accommodate a dry mouth and poorly fitting
3. What’s in your favorite fast-food meal? dentures?
a. Use the Internet or a diet analysis computer program
to look up the nutrient composition of your favorite
fast-food meal.
SUMMARY
1. Good nutrition in childhood sets the stage for Eating disorders are more common in adolescence than
nutrition and health in the adult years. Diets high at any other time. Adolescent athletes are susceptible to
in energy, saturated fat, cholesterol, sugar, and salt nutrition misinformation, and they may try dangerous
promote the development of obesity, diabetes, high practices such as using anabolic steroids to increase
blood cholesterol, and high blood pressure even muscle mass or fad diets and fluid restriction to lose
in children, and these conditions follow them weight.
into adulthood. Healthy eating habits learned in
childhood can reduce the risk of chronic disease 8. Aging is the accumulation of changes over time that
later in life. results in an ever-increasing susceptibility to disease and
death. A combination of genetic, environmental, and
2. Total energy and nutrient needs increase as children lifestyle factors determines how long people live and
grow because of the increase in total body weight and how long they remain healthy. As a population, we are
activity level. The proportion of fat needed in the diets living longer but not necessarily healthier lives. Good
of young children is much lower than in infancy but nutrition is important for increasing the number of
still somewhat higher than in adults. Carbohydrates healthy years.
should come primarily from whole grains, vegetables,
fruits, and milk. Iron deficiency remains a problem 9. The physiological changes that occur with age affect
among children and inadequate calcium intake the ability to acquire, consume, digest, absorb, and
contributes to low peak bone mass. metabolize nutrients. Energy needs are reduced so a
nutrient-dense diet is needed to meet needs. Fluid
3. A varied diet can meet children’s nutrient needs needs are not different but the risk of dehydration is
without dietary supplements, but skipped meals, food increased. Vitamin B12 requirements are the same but
jags, and erratic eating habits can make meeting needs the vitamin should come from fortified foods or
a challenge. In children as well as infants and teens, supplements in order to ensure adequate absorption.
growth that follows standard patterns indicates The requirements for calcium and vitamin D are
adequate nutrition. increased and it may be hard for older adults to get
enough of either from diet alone.
4. High-sugar diets can contribute to tooth decay but
there is no evidence they cause hyperactivity. Exposure
to lead affects brain development. Television contributes 10. Both physical limitations and chronic diseases affect
to inactivity and poor food choices in children. nutrient requirements and the ability to consume a
nutritious diet. The medications used to treat disease
5. During adolescence, accelerated growth and sexual also affect nutritional status, especially when the
maturation have an impact on nutrient requirements. medications are taken over long periods of time and
Body composition and the nutritional requirements of when multiple medications are taken simultaneously.
boys and girls diverge. Boys gain more lean body tissue, The DETERMINE checklist helps identify older adults
while girls gain proportionately more body fat. During who are at risk for malnutrition.
the adolescent growth spurt, total energy and protein
requirements are higher than at any other time of life. 11. To meet nutrient needs the elderly must overcome
Young men require more protein and energy than economic limitations and social isolation. The federal
young women. Older Americans Act includes programs that provide
older adults with low-cost or free meals in their homes
6. In adolescence, vitamin requirements increase or in a social setting. Although these programs are
to meet the needs of rapid growth. The minerals helpful, they do not ensure adequate nutrition for all
iron, calcium, and zinc are likely to be low in the elderly people.
adolescent diet. Iron deficiency anemia is common,
especially in girls as they begin losing iron through 12. Alcohol has short-term effects on the central nervous
menstruation. Consuming too much fast food system, including impairment of reasoning, judgment,
contributes to a diet that is high in calories, fat, and coordination, and eventually the loss of
and salt and low in calcium, fiber, and vitamins A consciousness. Chronic alcohol use damages the liver
and C. Vegetarian diets can be a problem if not well and can cause malnutrition by decreasing nutrient
constructed. intake and absorption and interfering with nutrient
utilization. Some groups should never drink, but
7. Psychosocial changes occurring during the adolescent moderate alcohol consumption can have health
years make physical appearance of great concern. benefits in others.
References 485
REVIEW QUESTIONS
1. How does nutrient intake during childhood affect the 12. What is life expectancy? How does it differ from healthy
risk of chronic disease later in life? life expectancy?
2. What is the best way to determine if a child is eating 13. List three physiological changes that occur with aging.
enough? 14. Why is it so important that elderly individuals consume
3. What impact do parents’ weights have on children’s a nutrient-dense diet?
weights? 15. What social and economic factors increase nutritional
4. What factors influence the maximum height a child will risk among the elderly?
reach? 16. Why are older adults at risk of vitamin B12 deficiency?
5. How do the recommendations for fat intake change as Vitamin D deficiency?
children get older? 17. How can nutrition affect your risk of developing
6. Why is anemia a problem in young children? In teenage macular degeneration?
girls? 18. Explain why physical disabilities and mental illness
7. Why are snacks an important part of children’s diets? affect nutritional status.
8. Why is breakfast important? 19. What are the short-term effects of alcohol?
9. How can fast foods be incorporated into a healthy diet? 20. What effects does alcohol have on the liver?
10. What is the adolescent growth spurt? How does it affect 21. What are the benefits of alcohol consumption?
nutrient requirements?
11. Why are teenagers particularly susceptible to eating
disorders?
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Good Nutrition Early On Is Key

Healthy eating habits keep children healthy

Many children and teens have elevated blood choles-

Healthy eating habits are learned

Nourishing Young Children Can Be a Challenge

Children’s energy and nutrient needs increase

Your Choice: No Bones About It?

Are you thirsty? How about an ice-cold cola? It shouldn’t

Amount Per Serving

section of convenience stores is filled with bottles and cans

of these carbonated concoctions and they take up an entire

aisle in the supermarket. They have become a part of

American culture—we think of them as a thirst quencher, a

Too Many Calories, Too Little Iron

A balanced varied diet will meet children’s

Creativity helps encourage young children to consume a

Your Choice: Breakfast

(Leigh Beisch/Foodpix/PictureArts Corp.)

Vitamin and mineral supplements are not necessary As

Nutritious meals at day care or school are important All

Normal growth is the best indicator

Off the Label: Labeling Food

Amount Per Serving

% Daily Value 0-1 1-4

Child and adolescent growth can be monitored by comparing growth to standard

Too little growth may mean undernutrition When a child’s

CDC Growth Charts: United States

A high BMI may indicate a risk of becoming overweight

Mild calorie restriction can allow for growth with little

Increasing physical activity increases energy expenditure

Fitness Pyramid for Kids

KICK IT ZONE Frequency: 3 times per week

HEALTHY HEART ZONE

FAT BURNING ZONE

*HRM—Heart Rate Maximum

Diet and lifestyle affect nutritional risks For more information

Hyperactivity has not been found to be related to sugar

Lead from the environment harms the developing ner-

Too much television reduces activity and influences

Saturday Morning Pyramid

So, What Should I Eat?

Serve children frequent nutritious meals and snacks

Adolescents Have Changing Bodies

Hormones cause sexual maturation and

Average body composition

Total energy and nutrient needs are greatest

Vitamin needs are increased by growth and high energy

The iron needs of adolescent girls are even higher than

Increases in bone length and mass increase calcium

Mild zinc deficiency can affect growth and development

Teens must learn to make healthy

So, What Should I Eat?

Balance less healthy choices with healthy ones

Vegetarian diets are not always as healthy as they could

Concerns about appearance and performance

Eating disorders are most common in adolescence Eating

Athletes may use supplements and diets to enhance

Good Nutrition Can Keep Adults Healthy

Aging begins at birth

How long you live is determined by your genes,

Good nutrition can prolong our healthy years Although nutri-