NUTRIENTSNUTRIENTSandand

ASSESSMENT ASSESSMENT

Myrna D.C. San Pedro, MD, FPPSMyrna D.C. San Pedro, MD, FPPS

Specific ObjectivesSpecific Objectives To discuss the importance of nutritionTo discuss the importance of nutrition

Correlate nutrition with growthCorrelate nutrition with growthDefine nutrition and other associated termsDefine nutrition and other associated termsDiscuss energy requirement and Discuss energy requirement and

expenditureexpenditureDiscuss body composition and growthDiscuss body composition and growth

To discuss all essential nutrients as to their To discuss all essential nutrients as to their functions, sources and requirementsfunctions, sources and requirements

To discuss a comprehensive pediatric To discuss a comprehensive pediatric nutritional assessmentnutritional assessment

NUTRITION & GROWTHNUTRITION & GROWTH Unique nutritional needs of infants and Unique nutritional needs of infants and

children children Rapid growth especially during 1Rapid growth especially during 1stst year of year of

lifelife3-fold increase in weight3-fold increase in weight50% increase in length50% increase in length

Higher metabolic ratesHigher metabolic ratesMarked developmental organ changesMarked developmental organ changes

Good nutrition helpsGood nutrition helpsDevelop physical and mental potential Develop physical and mental potential Provide reserves for stressProvide reserves for stressPrevent acute and chronic illnessPrevent acute and chronic illness

NUTRITIONNUTRITION

Combination of processes by whichCombination of processes by which

Organism receives & uses materialsOrganism receives & uses materials

Needed forNeeded forGrowthGrowthFunctions Functions Repair of partsRepair of parts

METABOLISMMETABOLISM

All the changes in foodstuffsAll the changes in foodstuffs

From absorption in the GIT untilFrom absorption in the GIT until

Elimination by excretory organs Elimination by excretory organs

NUTRIENT REQUIREMENTNUTRIENT REQUIREMENT

Amount neededAmount neededTo replace obligatory lossesTo replace obligatory lossesTo support synthesisTo support synthesisVaries by age, sex, size & Varies by age, sex, size &

growth rategrowth rate

ENERGY EXPENDITUREENERGY EXPENDITURE

1.1. Basal Metabolic Rate (BMR)Basal Metabolic Rate (BMR)

2.2. Specific Dynamic Action Specific Dynamic Action (SDA) or Thermic Effect of (SDA) or Thermic Effect of Food (TEF)Food (TEF)

3.3. Body activityBody activity

4.4. Fecal lossesFecal losses

5.5. Growth allowanceGrowth allowance

1)1) Basal Metabolic Rate (BMR)Basal Metabolic Rate (BMR) Energy expenditure of awake individualEnergy expenditure of awake individual

At restAt restAt room temperature (20At room temperature (2000 C) C) After overnight or 14 hours fastingAfter overnight or 14 hours fasting

Most closely related to lean body mass Most closely related to lean body mass Factors: metabolic disorders, surgery, Factors: metabolic disorders, surgery,

infections, anorexia or fever*infections, anorexia or fever* 50-100% in infants and 20-25% in 50-100% in infants and 20-25% in

adults to maintain temperatureadults to maintain temperature InIn infants about 55 kcalinfants about 55 kcal****/kg/day/kg/day which which

decreases to decreases to 25-30 kcal/kg/day at 25-30 kcal/kg/day at maturitymaturity

2)2) Specific Dynamic Action Specific Dynamic Action (SDA)(SDA)or Thermic Effect of Food or Thermic Effect of Food (TEF)(TEF) Increase in heat production due to Increase in heat production due to

digestion and assimilation of fooddigestion and assimilation of food Highest for proteins (30%) but low Highest for proteins (30%) but low

for carbohydrates (6%) and fat (4%)for carbohydrates (6%) and fat (4%) In infants about 7-8% of intake but in In infants about 7-8% of intake but in

older children not more than 5%older children not more than 5% About About 5 kcal/kg/day5 kcal/kg/day

3)3) Body activityBody activity (physical & exercise):(physical & exercise): average need is average need is 15-25 kcal/kg/day 15-25 kcal/kg/day but may be as high asbut may be as high as 50-80 50-80 kcal/kg/day kcal/kg/day forfor short periodsshort periods

4)4) Fecal losses: Fecal losses: amount of energy-amount of energy-producing food in stools (unused producing food in stools (unused fats & proteins) not more than 10% fats & proteins) not more than 10% of intake or about of intake or about 8 kcal/kg/day8 kcal/kg/day

5)5) Growth allowance:Growth allowance: during 1 during 1stst 4 mo 4 mo about about 15-20 kcal/kg/day15-20 kcal/kg/day which which decreases todecreases to 12 kcal/kg/day 12 kcal/kg/day at end at end 11stst year year

Thus, the energy requirement of the Thus, the energy requirement of the infant or child is the level of intake infant or child is the level of intake which canwhich can

Maintain appropriate body size & composition

As well as deposition of new tissues

Meet the energy required for physical activity

And the thermic effect of food

Daily Caloric Daily Caloric RequirementRequirement

Approximately Approximately 80-120 80-120 kcal/kgkcal/kg body weight for body weight for the the 11stst year year

Decreasing Decreasing subsequently subsequently by about by about 10 kcal/kg10 kcal/kg body body weight weight every 3-yearevery 3-year period period

Energy Expenditure 6-12 Energy Expenditure 6-12 YearsYears

Basal metabolism Basal metabolism 50%50%

SDA or TEF 5%SDA or TEF 5% Physical activity 25%Physical activity 25% Fecal loss 8%Fecal loss 8% Growth 12%Growth 12%

Body CompositionBody Composition Fat-free mass (FFM)Fat-free mass (FFM)* component consists of:* component consists of:

WaterWater 60-65% body weight (BW) adults while 70- 60-65% body weight (BW) adults while 70-75% BW infants75% BW infants

ProteinsProteins 20% BW adults 20% BW adults Carbohydrates Carbohydrates not more than 1% BWnot more than 1% BW Mineral contentMineral content 4.35% BW adults but 3% BW at 4.35% BW adults but 3% BW at

birthbirth Fat mass (FM)Fat mass (FM) component: 13-17% BW (or not >25%) component: 13-17% BW (or not >25%)

in males and 20-25% (or not >30%) BW in females 6-in males and 20-25% (or not >30%) BW in females 6-18 years of age**18 years of age**

Why the need to know and measure body composition:Why the need to know and measure body composition: The rising prevalence of childhood obesity (>FM)The rising prevalence of childhood obesity (>FM) For assessment and treatment of growth disordersFor assessment and treatment of growth disorders An important index of energy and fluid requirements An important index of energy and fluid requirements

(FFM(FFM size) during artificial nutritionsize) during artificial nutrition

MAJOR NUTRIENTSMAJOR NUTRIENTS

1.1. CarbohydratesCarbohydrates

2.2. ProteinsProteins

3.3. FatsFats

4.4. WaterWater

5.5. MineralsMinerals

6.6. VitaminsVitamins

MacronutrieMacronutrientsnts

MicronutrienMicronutrientsts

Macronutrients Provide Macronutrients Provide EnergyEnergy

1.1. Carbohydrates (CHO): Carbohydrates (CHO): 1 g = 4 kcal1 g = 4 kcal Enough CHO to prevent ketosis and/or Enough CHO to prevent ketosis and/or

hypoglycemia = 5 g/kg/24 hrhypoglycemia = 5 g/kg/24 hr2.2. Proteins: Proteins: 1 g = 4 kcal1 g = 4 kcal3.3. FatsFats: 1 g long-chain = 9 kcal: 1 g long-chain = 9 kcal

1 g medium-chain = 8.3 kcal1 g medium-chain = 8.3 kcal1 g short-chain = 5.3 kcal1 g short-chain = 5.3 kcal

Enough fat to provide essential fatty Enough fat to provide essential fatty acid (EFA) requirements = 0.5-1 acid (EFA) requirements = 0.5-1 g/kg/24 hrg/kg/24 hr

Thus, minimal needs for Thus, minimal needs for CHO and fatsCHO and fats not more than not more than 30 kcal/kg/24 hr30 kcal/kg/24 hr or only or only about about 1/3 of total energy needs1/3 of total energy needs

Carbohydrates’ FunctionsCarbohydrates’ Functions1.1. Readily available & supply most of body’s energy Readily available & supply most of body’s energy

needsneeds Primary role to provide energy to cells in body, Primary role to provide energy to cells in body,

especially the brain - the only carbohydrate-especially the brain - the only carbohydrate-dependent organ in bodydependent organ in body

2.2. AntiketogenicAntiketogenic3.3. Structure of cellsStructure of cells4.4. Store calories as glycogenStore calories as glycogen5.5. Convert to fatConvert to fat6.6. Amino acid synthesisAmino acid synthesis7.7. Fiber: Dietary (e.g. cellulose) & Functional (e.g. Fiber: Dietary (e.g. cellulose) & Functional (e.g.

Psyllium)Psyllium) Promote normal laxation, help prevent diet-related Promote normal laxation, help prevent diet-related

cancer, help reduce serum cholesterol levels, hence, cancer, help reduce serum cholesterol levels, hence, risk of coronary heart disease (CHD) and help risk of coronary heart disease (CHD) and help prevent obesity and risk of adult-onset diabetesprevent obesity and risk of adult-onset diabetes

Proteins’ FunctionsProteins’ Functions1.1. Supply amino acids for growth & repair Supply amino acids for growth & repair

of body tissuesof body tissues

2.2. Supply ions in acid-base balanceSupply ions in acid-base balance

3.3. Part of hemoglobin, nucleoproteins, Part of hemoglobin, nucleoproteins, glycoproteins & lipoproteinsglycoproteins & lipoproteins

4.4. As enzymes, hormones, antibodies & As enzymes, hormones, antibodies & cellular respiratory substancescellular respiratory substances

5.5. Protective structure (nails & hair)Protective structure (nails & hair)

6.6. Source of energy when there is Source of energy when there is shortage of fats & carbohydratesshortage of fats & carbohydrates

Daily Protein RequirementDaily Protein Requirement2005 Dietary Reference Intakes, U. S. Food 2005 Dietary Reference Intakes, U. S. Food and Nutrition Board, National Academy of and Nutrition Board, National Academy of

Sciences Sciences (g/kg BW/day)(g/kg BW/day)

1978 FNRI Publications, 1978 FNRI Publications, Daily Requirements of Daily Requirements of

Filipinos Filipinos (g/kg BW/day)(g/kg BW/day)

0-6 mo (AI)0-6 mo (AI) 1.521.52 0-5 mo 0-5 mo 3.53.5

7-12 mo (RDA)7-12 mo (RDA) 1.2 (or 11 g/day of protein)1.2 (or 11 g/day of protein) 6-11 mo6-11 mo 33

1-3 yr (RDA)1-3 yr (RDA) 1.05 (or 13 g/day of protein)1.05 (or 13 g/day of protein) 1-2 yr1-2 yr 2.52.5

4-8 yr (RDA)4-8 yr (RDA) 0.95 (or 19 g/day of protein)0.95 (or 19 g/day of protein) 3-6 yr3-6 yr 22

9-13 yr (RDA)9-13 yr (RDA) 0.95 (or 34 g/day of protein)0.95 (or 34 g/day of protein) 7-15 yr7-15 yr 1.51.5

MalesMales 16-19 yr16-19 yr 1.21.2

14-18 yr (RDA)14-18 yr (RDA)19-30 yr (RDA)19-30 yr (RDA)

0.85 (or 52 g/day of protein)0.85 (or 52 g/day of protein)0.80 (or 56 g/day of protein)0.80 (or 56 g/day of protein)

FemalesFemales

14-18 yr (RDA)14-18 yr (RDA)19-30 yr (RDA)19-30 yr (RDA)

0.85 (or 46 g/day of protein)0.85 (or 46 g/day of protein)0.80 (or 46 g/day of protein)0.80 (or 46 g/day of protein)

As point of reference: 3 ounces lean beef (the size of a deck of cards) or poultry = As point of reference: 3 ounces lean beef (the size of a deck of cards) or poultry = 25 g protein; 3 ounces fish or 1 cup soybeans = 20 g protein; 1 cup milk or yogurt 25 g protein; 3 ounces fish or 1 cup soybeans = 20 g protein; 1 cup milk or yogurt = 8 g protein; 1 egg or 1 ounce cheese=6 g protein; 1 cup legumes=15 g = 8 g protein; 1 egg or 1 ounce cheese=6 g protein; 1 cup legumes=15 g protein; cereals, grains, nuts and vegetables = 2 g protein per servingprotein; cereals, grains, nuts and vegetables = 2 g protein per serving

Amino AcidsAmino Acids

24 amino acids identified24 amino acids identified

Dietary Reference Intakes of Dietary Reference Intakes of Essential Amino AcidsEssential Amino Acids

Amino AcidAmino Acid(mg/kg/24 hr)(mg/kg/24 hr)

0-6 0-6 momo

7-12 7-12 momo 1-3 yr1-3 yr 4-8 4-8

yryr

Aromatic amino Aromatic amino acidsacids

120120 6161 4646 3838

IsoleucineIsoleucine 7878 3636 2828 2525

LeucineLeucine 139139 7171 5656 4747

LysineLysine 9595 6666 5151 4343

Sulfur amino acidsSulfur amino acids 5252 3232 2525 2121

ThreonineThreonine 6565 3636 2727 2222

TryptophanTryptophan 2525 1010 77 66

ValineValine 7777 4242 3232 2727

Evaluating Protein QualityEvaluating Protein Quality1.1. Protein Efficiency Ratio (PER)Protein Efficiency Ratio (PER)

Wt gained/gm protein consumedWt gained/gm protein consumed U. S. FDA used PER as basis on food labels but U. S. FDA used PER as basis on food labels but

PER based on amino acid requirements of PER based on amino acid requirements of growing ratsgrowing rats

2.2. Biologic Value (BV) of proteinBiologic Value (BV) of protein Amount of nitrogen accumulated compared with Amount of nitrogen accumulated compared with

nitrogen absorbednitrogen absorbed Indicates effectiveness of utilization but does not Indicates effectiveness of utilization but does not

account for certain factors influencing digestionaccount for certain factors influencing digestion3.3. Net Protein Utilization (NPU)Net Protein Utilization (NPU)

Percentage of nitrogen consumed that is retained Percentage of nitrogen consumed that is retained by the bodyby the body

Influenced by factors other than inherent Influenced by factors other than inherent composition such as reduced digestibility due to composition such as reduced digestibility due to overheating lowering protein value by decreasing overheating lowering protein value by decreasing availability of essential amino acidsavailability of essential amino acids

Evaluating Protein QualityEvaluating Protein Quality4.4. Amino Acid Score (AAS)Amino Acid Score (AAS)

A A chemical techniquechemical technique measuring measuring indispensable amino acids in a protein and indispensable amino acids in a protein and comparing values with a reference proteincomparing values with a reference protein

Fast, consistent and inexpensiveFast, consistent and inexpensive5.5. Protein Digestibility Corrected Amino Acid Protein Digestibility Corrected Amino Acid

Score (PDCAAS )Score (PDCAAS ) The currently accepted measureThe currently accepted measure Advantages:Advantages: (1)(1) Based on the amino acid Based on the amino acid

requirements of humans requirements of humans (2)(2) AAS plus AAS plus digestibility componentdigestibility component

Limitations:Limitations: (1)(1) Takes no account of where Takes no account of where the proteins have been digested the proteins have been digested (2)(2) Incomplete since human diets almost never Incomplete since human diets almost never contain only one kind of proteincontain only one kind of protein

Fats’ FunctionsFats’ Functions1.1. A concentrated & reserve source of energyA concentrated & reserve source of energy2.2. Physical protection for vessels, nerves, organsPhysical protection for vessels, nerves, organs3.3. Insulation against changes in temperatureInsulation against changes in temperature4.4. Supply essential fatty acids: linoleic & Supply essential fatty acids: linoleic & -linolenic -linolenic

acidsacids5.5. Structure of body tissues & cell membranes & nucleiStructure of body tissues & cell membranes & nuclei

Long-chain polyunsaturated fatty acids (LC-PUFA) Long-chain polyunsaturated fatty acids (LC-PUFA) especially arachidonic acid (ARA) and especially arachidonic acid (ARA) and docosahexanoic acid (DHA) most prevalent in docosahexanoic acid (DHA) most prevalent in brain and photoreceptor membranesbrain and photoreceptor membranes

6.6. Carry the fat-soluble vitamins (A, D, E & K)Carry the fat-soluble vitamins (A, D, E & K)7.7. Give appetite appealGive appetite appeal8.8. Aid satiety (delay emptying time of stomach)Aid satiety (delay emptying time of stomach)9.9. Spare proteinSpare protein

Essential Fatty Acids (EFAs)Essential Fatty Acids (EFAs) Linoleic acid (LA) Linoleic acid (LA) andand -linolenic acid (ALA)-linolenic acid (ALA) Necessary for growth, skin & hair integrity, Necessary for growth, skin & hair integrity,

cholesterol metabolism, lipotropic activity, cholesterol metabolism, lipotropic activity, decreased platelet adhesiveness and reproductiondecreased platelet adhesiveness and reproduction

Diets with <1-2% kcal of EFAs slow down growth Diets with <1-2% kcal of EFAs slow down growth rate, cause intertrigo or scaly rash and poor wound rate, cause intertrigo or scaly rash and poor wound healing healing

The The right ratio of LA to ALA in the diet 3:1 or 2:1 right ratio of LA to ALA in the diet 3:1 or 2:1 importantimportant since an imbalance may lead to a since an imbalance may lead to a variety of mental disorders including hyperactivity, variety of mental disorders including hyperactivity, depression, brain allergies and schizophreniadepression, brain allergies and schizophrenia

LA is abundant in soy oil, sesame seeds, corn oil, LA is abundant in soy oil, sesame seeds, corn oil, and most nuts while ALA is abundant in flax, small and most nuts while ALA is abundant in flax, small quantities in walnuts, canola oil, wheat germ and quantities in walnuts, canola oil, wheat germ and dark green leafy vegetablesdark green leafy vegetables

Omega-3 and Omega-6 FatsOmega-3 and Omega-6 Fats LC-PUFA: >18 carbons in length with LC-PUFA: >18 carbons in length with >>2 2 ciscis double double

bondsbonds Most relevant to infant nutrition: Most relevant to infant nutrition: ARA (20:4n-6) ARA (20:4n-6) andand

DHA (22:6n-3)DHA (22:6n-3) Infants can convert LA (18:2n-6) Infants can convert LA (18:2n-6) andand ALA (18:3n-3) to ALA (18:3n-3) to

ARA ARA andand DHA DHA, , respectivelyrespectively ARA and DHA most prevalent in CNS suggesting ARA and DHA most prevalent in CNS suggesting

importance to CNS function so that brain depletion importance to CNS function so that brain depletion can result in learning deficitscan result in learning deficits

DHA about 40% of retinal photoreceptor membrane DHA about 40% of retinal photoreceptor membrane fatty acids, hence, important for visual and fatty acids, hence, important for visual and neurological developmentneurological development

However, variable research data as to advantages of However, variable research data as to advantages of LC-PUFA–supplemented formulas* so that there is LC-PUFA–supplemented formulas* so that there is no no recommendation yet with regards to LC-PUFA recommendation yet with regards to LC-PUFA supplementationsupplementation

EicosanoidsEicosanoids derived from derived from DGLADGLA,, ARA ARA and and EPAEPA have have critical critical roles in immune and inflammatory responsesroles in immune and inflammatory responses by by being formed into prostaglandins and leukotrienesbeing formed into prostaglandins and leukotrienes

EPA eicosanoids less potent inducers of inflammation, EPA eicosanoids less potent inducers of inflammation, blood vessel constriction, and coagulation than from ARA blood vessel constriction, and coagulation than from ARA

When levels of omega-6 ARA, found in most oils and When levels of omega-6 ARA, found in most oils and meat, high in brains of rats, they showed signs of meat, high in brains of rats, they showed signs of depressiondepression

According to Depression and Bipolar Support Alliance, According to Depression and Bipolar Support Alliance, depression most common serious brain disease in U. depression most common serious brain disease in U. S., affecting more than 23 million adults each yearS., affecting more than 23 million adults each year

Previous studies revealed decreased omega-3 fatty Previous studies revealed decreased omega-3 fatty acid intake could be responsibleacid intake could be responsible

The omega-6 LA comprises 7% to 9% of an American The omega-6 LA comprises 7% to 9% of an American daily caloric intake while omega-3 ALA makes up only daily caloric intake while omega-3 ALA makes up only 0.7%, thus, LA to ALA ratio 10-20:1, far more than 0.7%, thus, LA to ALA ratio 10-20:1, far more than recommended 2-3:1 and at which level ALA recommended 2-3:1 and at which level ALA metabolism suppressedmetabolism suppressed

Recent studies show that depression may be controlled Recent studies show that depression may be controlled by shifting balance -- cutting on omega-6 and by shifting balance -- cutting on omega-6 and increasing omega-3 to bring to right ratioincreasing omega-3 to bring to right ratio

REQUIREMENT vs REQUIREMENT vs RECOMMENDED INTAKE vs RECOMMENDED INTAKE vs

REFERENCE INTAKEREFERENCE INTAKE Estimated average requirement (EAR)Estimated average requirement (EAR) Recommended daily allowance (RDA)Recommended daily allowance (RDA) Dietary reference intakes (DRIs)Dietary reference intakes (DRIs)

Adequate intake (AI)Adequate intake (AI)Tolerable upper intake (UL)Tolerable upper intake (UL)

Estimated energy requirement (EER) Estimated energy requirement (EER)

Estimated Average Estimated Average Requirement Requirement

Amount of a nutrient that results in some Amount of a nutrient that results in some predetermined physiologic end-point*predetermined physiologic end-point*

Usually defined experimentally, often over Usually defined experimentally, often over relatively short period and in relatively relatively short period and in relatively small study populationsmall study population

Daily intake value estimated to meet the Daily intake value estimated to meet the needs of needs of half the healthy individualshalf the healthy individuals or or population in which it was establishedpopulation in which it was established

Used to calculate the RDA, to assess Used to calculate the RDA, to assess adequacy of group intakes and to plan adequacy of group intakes and to plan intake of groups intake of groups

Recommended Dietary Recommended Dietary AllowanceAllowance

Average daily nutrient intake level sufficient Average daily nutrient intake level sufficient to meet the nutrient requirement of to meet the nutrient requirement of most most healthy members (97-98%)healthy members (97-98%) of a population of a population

Set at the mean requirement (EAR) and Set at the mean requirement (EAR) and normally distributed plus 2 standard normally distributed plus 2 standard deviationsdeviations

Used as goal for daily intake by individuals since estimates an intake level that has a high probability of meeting the requirement of a randomly chosen individual (about 97.5%)

Dietary Reference IntakesDietary Reference Intakes Recommendations in the 2005 U.S. Food and Nutrition Recommendations in the 2005 U.S. Food and Nutrition

Board, National Academy of Sciences ReportBoard, National Academy of Sciences Report Include RDAs with EAR as well as AI and ULInclude RDAs with EAR as well as AI and UL AI: Estimates of observed median daily nutrient intakes by AI: Estimates of observed median daily nutrient intakes by

a group (or groups) of apparently healthy peoplea group (or groups) of apparently healthy peopleUsed when an RDA cannot be established but not sameUsed when an RDA cannot be established but not sameSet at the amount in average volume of milk consumed Set at the amount in average volume of milk consumed

by healthy, normally growing breast-fed infants 0-6 mo by healthy, normally growing breast-fed infants 0-6 mo Set at the amount in average volume of human milk plus Set at the amount in average volume of human milk plus

average amount of complementary foods by healthy, average amount of complementary foods by healthy, normally growing 7-12 mo old infantsnormally growing 7-12 mo old infants

UL: Highest daily intake of a nutrient likely to pose no riskUL: Highest daily intake of a nutrient likely to pose no riskAn aid for avoiding excessive intake and adverse effectsAn aid for avoiding excessive intake and adverse effects

DRIs vs Former RDAs & RNIsDRIs vs Former RDAs & RNIs Main uses same: diet assessment and diet Main uses same: diet assessment and diet

planningplanning Differences of DRIs from U.S. former RDAs and Differences of DRIs from U.S. former RDAs and

Canada’s recommended nutrient intakes (RNIs):Canada’s recommended nutrient intakes (RNIs):1)1) Reduction in risk of chronic degenerative Reduction in risk of chronic degenerative

disease included in formulation rather than disease included in formulation rather than just absence of signs of deficiencyjust absence of signs of deficiency

2)2) UL established where data regarding risk of UL established where data regarding risk of adverse health effects existadverse health effects exist

3)3) Components of food that may not meet Components of food that may not meet traditional concept of nutrient but of possible traditional concept of nutrient but of possible benefit to health reviewed and when enough benefit to health reviewed and when enough data exist, reference intakes establisheddata exist, reference intakes established

Estimated Energy RequirementEstimated Energy Requirement Daily requirement for energy as defined by the Daily requirement for energy as defined by the

DRIsDRIs predicted to maintain energy balance in a predicted to maintain energy balance in a healthy individual of a defined age, sex, weight, healthy individual of a defined age, sex, weight, height (length) and level of physical activityheight (length) and level of physical activity

Based on calculations that account for an Based on calculations that account for an individual’s age, sex, weight, height, energy individual’s age, sex, weight, height, energy intake, energy expenditure intake, energy expenditure measured by doubly measured by doubly labeled water methodlabeled water method plus an allowance for plus an allowance for energy deposition and physical activity levelenergy deposition and physical activity level

The motivation for EER tied to public health The motivation for EER tied to public health awareness and concern about increased awareness and concern about increased prevalence of overweight and obesity in North prevalence of overweight and obesity in North America and the need to adequately assess America and the need to adequately assess energy balanceenergy balance

Expressed per unit of body weight, EER of normal Expressed per unit of body weight, EER of normal infant about twice of normal adultinfant about twice of normal adult

Equations to Estimate Energy Equations to Estimate Energy RequirementRequirement

Ages 0-36 months EER (kcal/day) = TEE + energy depositionAges 0-36 months EER (kcal/day) = TEE + energy deposition

0-3 mo0-3 mo (89 x weight [kg] - 100) + 175 kcal(89 x weight [kg] - 100) + 175 kcal

4-6 mo4-6 mo (89 x weight [kg] - 100) + 56 kcal(89 x weight [kg] - 100) + 56 kcal

7-12 mo7-12 mo (89 x weight [kg] - 100) + 22 kcal(89 x weight [kg] - 100) + 22 kcal

13-36 mo13-36 mo (89 x weight [kg] - 100) + 20 kcal(89 x weight [kg] - 100) + 20 kcal

Male 3-18 years EER = TEE + energy depositionMale 3-18 years EER = TEE + energy deposition

3-8 yr3-8 yr 88.5 - (61.9 x age [y])+ PA x (26.7 x weight [kg]) + (903 x height [m]) + 88.5 - (61.9 x age [y])+ PA x (26.7 x weight [kg]) + (903 x height [m]) + 20 kcal20 kcal

9-18 yr9-18 yr 88.5 - (61.9 x age [y]) + PA x (26.7 x weight [kg]) + (903 x height [m]) 88.5 - (61.9 x age [y]) + PA x (26.7 x weight [kg]) + (903 x height [m]) + 25 kcal+ 25 kcal

Female 3-18 years EER = TEE + energy depositionFemale 3-18 years EER = TEE + energy deposition

3-8 yr3-8 yr 135.3 - (30.8 x age [y]) + PA x (10 x weight [kg])+ (934 x height [m]) + 135.3 - (30.8 x age [y]) + PA x (10 x weight [kg])+ (934 x height [m]) + 20 kcal20 kcal

9-18 yr9-18 yr 135.3 - (30.8 x age [y]) + PA x (10 x weight [kg])+ (934 x height [m]) + 135.3 - (30.8 x age [y]) + PA x (10 x weight [kg])+ (934 x height [m]) + 25 kcal25 kcal

Ages 19 years and older EER (kcal/day) = TEEAges 19 years and older EER (kcal/day) = TEE

MaleMale 662 - (9.53 x age [y]) + PA x (15.91 x weight [kg]) + (539.6 x height 662 - (9.53 x age [y]) + PA x (15.91 x weight [kg]) + (539.6 x height [m])[m])

FemalFemalee

354 - (6.91 x age [y]) + PA x (9.36 x weight [kg]) + (726 x height [m])354 - (6.91 x age [y]) + PA x (9.36 x weight [kg]) + (726 x height [m])

WaterWater Essential for lifeEssential for life Normal infant absolute requirement Normal infant absolute requirement

probably 75-100 ml/kg/24 hrprobably 75-100 ml/kg/24 hr Of fluid intake: water retained 0.5-Of fluid intake: water retained 0.5-

3%, evaporated from lungs & skin 3%, evaporated from lungs & skin 40-50%, fecal losses 3-10% & renal 40-50%, fecal losses 3-10% & renal excretion excretion >>40-50%40-50%

Daily consumption: 10-15% BW Daily consumption: 10-15% BW healthy infant versus 2-4% BW in healthy infant versus 2-4% BW in adultadult

MineralsMineralsMacromineralsMacrominerals

Sodium Sodium 1gm or 2mEq/kg1gm or 2mEq/kg

PotassiumPotassium 1-2gm or 1-2gm or 1.5mEq/kg1.5mEq/kg

CalciumCalcium 0.6gm/day 0.6gm/day MagnesiumMagnesium

150-300mg/day150-300mg/day ChlorineChlorine 0.5gm/day 0.5gm/day PhosphorusPhosphorus SulfurSulfur 0.5-1gm/day 0.5-1gm/day

MicromineralsMicrominerals Iron Iron 1mg/kg/day1mg/kg/day IodineIodine 34-45 mcg/day 34-45 mcg/day Copper Copper

0.5-1mg/kg/day0.5-1mg/kg/day FluorineFluorine 0.5-1mg/day 0.5-1mg/day ZincZinc 3-5mg/kg/day 3-5mg/kg/day Cobalt Cobalt 1-2mcg/day1-2mcg/day ManganeseManganese

0.05-1.5mg/day0.05-1.5mg/day ChromiumChromium

0.02-0.10mg/day0.02-0.10mg/day SeleniumSelenium

0.02-0.10mg/day0.02-0.10mg/day MolybdenumMolybdenum

0.05-0.15mg/day0.05-0.15mg/day

MacromineralsMacrominerals Sodium, Chloride, PotassiumSodium, Chloride, Potassium work together to work together to

regulate the flow of fluids in the body & help regulate the flow of fluids in the body & help regulate the nervous system, muscle functions & regulate the nervous system, muscle functions & nutrient absorption in the cellsnutrient absorption in the cells

CalciumCalcium is needed for bone rigidity, blood clotting, is needed for bone rigidity, blood clotting, muscle contraction & normal nerve functionsmuscle contraction & normal nerve functions

PhosphorousPhosphorous aids in all phases of calcium aids in all phases of calcium metabolism & helps build strong bones & teethmetabolism & helps build strong bones & teeth

MagnesiumMagnesium helps regulate body temperature, helps regulate body temperature, muscle contractions, the nervous system & helps muscle contractions, the nervous system & helps cells utilize carbohydrates, fats, and proteinscells utilize carbohydrates, fats, and proteins

SulfurSulfur helps in detoxification reactions, present in helps in detoxification reactions, present in amino acids in proteins & a component of amino acids in proteins & a component of mucopolysaccharides & essential compoundsmucopolysaccharides & essential compounds

MicromineralsMicrominerals IronIron combines with protein to form hemoglobin combines with protein to form hemoglobin Iodine Iodine needed by thyroid gland for thyroxineneeded by thyroid gland for thyroxine CopperCopper necessary in the formation of necessary in the formation of

hemoglobinhemoglobin FluorineFluorine helps reduce incidence of tooth decay helps reduce incidence of tooth decay Zinc Zinc important in the formation of protein, thus, important in the formation of protein, thus,

assists in wound healing, blood formation and assists in wound healing, blood formation and general growth & maintenance of all tissuesgeneral growth & maintenance of all tissues

Manganese Manganese necessary for normal development necessary for normal development of bones and connective tissuesof bones and connective tissues

ChromiumChromium maintains normal glucose uptake maintains normal glucose uptake into cells & helps insulin bind to cellsinto cells & helps insulin bind to cells

SeleniumSelenium w/vitamin E protect cells from w/vitamin E protect cells from destructiondestruction

Molybdenum, Molybdenum, a component of xanthine oxidase a component of xanthine oxidase and aldehyde oxidaseand aldehyde oxidase

VitaminsVitamins Organic compounds in minute amounts that catalyze Organic compounds in minute amounts that catalyze

cellular metabolismcellular metabolism Cannot be biosynthesized by our bodies so must be Cannot be biosynthesized by our bodies so must be

supplied by the diet or taken as supplements supplied by the diet or taken as supplements To date, there are 13 essential vitamins as included in To date, there are 13 essential vitamins as included in

the 2005 DRIs by the U.S. Food and Nutrition Board, the 2005 DRIs by the U.S. Food and Nutrition Board, National Academy of SciencesNational Academy of Sciences

Classified asClassified as Water-soluble: Water-soluble: Thiamin (B1), Riboflavin (B2), Thiamin (B1), Riboflavin (B2),

Niacin (B3), Pantothenic acid (B5), Pyridoxine (B6), Niacin (B3), Pantothenic acid (B5), Pyridoxine (B6), Biotin (B7) Folacin (B9), Cobalamin (B12) Biotin (B7) Folacin (B9), Cobalamin (B12) andand Ascorbic acid (C)Ascorbic acid (C)

Fat-soluble: Fat-soluble: Retinol (A), Cholecalciferol (D), Retinol (A), Cholecalciferol (D), Tocopherol (E) Tocopherol (E) andand Vitamin K Vitamin K

ASSESSMENT OF NUTRITIONAL ASSESSMENT OF NUTRITIONAL STATUS OF CHILDRENSTATUS OF CHILDREN

1.1. HistoryHistoryDietary history of mother & childDietary history of mother & childHistory of height & weight changesHistory of height & weight changes

2.2. Anthropometric indicatorsAnthropometric indicatorsEvidence of deviations from average Evidence of deviations from average height & weight height & weightEvidence of depletion of fat depotsEvidence of depletion of fat depotsEvidence of decrease in muscle massEvidence of decrease in muscle mass

3.3. Change in psychic reactionChange in psychic reaction4.4. Reaction to infectionReaction to infection5.5. Evidence of specific deficienciesEvidence of specific deficiencies

ANTHROPOMETRIC INDICATORS ANTHROPOMETRIC INDICATORS OF NUTRITIONAL STATUSOF NUTRITIONAL STATUS

1.1. Weight (Wt):Weight (Wt): index of acute nutritional index of acute nutritional status status

2.2. Height (Ht) or Length (Lt):Height (Ht) or Length (Lt): assesses growth assesses growth failure; unaffected by excess fat or fluid failure; unaffected by excess fat or fluid

3.3. Weight-for-Height:Weight-for-Height: assesses body build more assesses body build more accurately accurately A.A. Measure child’s heightMeasure child’s heightB.B. Find age for which measured height is on Find age for which measured height is on

the 50the 50thth% on the growth curve% on the growth curveC.C. Child’s actual weight (numerator)Child’s actual weight (numerator)

5050thth% wt based on age of plotted ht % wt based on age of plotted ht (denominator) (denominator)

A 6-yr-old boy has an actual weight of 15 kg A 6-yr-old boy has an actual weight of 15 kg & height of 105 cm. Compute for the wt-for-& height of 105 cm. Compute for the wt-for-ht%.ht%.

Actual Wt = 15 kgActual Ht = 105 cmIBW based on actual age (6 yr) = 20 kgIBW based on plotted Ht = 17 kg

Wt-for-Ht% = 15/17 = 0.88Wt-for-age% = 15/20 = 0.75Ht-for-age% = 105/110 = 0.95

4.4. Head circumference (HC):Head circumference (HC): influenced by nutrition influenced by nutrition till age 36 mo; <5till age 36 mo; <5thth% measurements may mean % measurements may mean chronic undernutrition fetal life & early childhoodchronic undernutrition fetal life & early childhood

5.5. Thickness skinfold (TSF):Thickness skinfold (TSF): estimates total body estimates total body fat fat

6.6. Mid-arm circumference (MAC)/Mid-arm muscle Mid-arm circumference (MAC)/Mid-arm muscle circumference (MAMC):circumference (MAMC): with TSF, determines with TSF, determines muscle area & fat areamuscle area & fat area MAMC = MAC – (3.4 x TSF)MAMC = MAC – (3.4 x TSF)

7.7. Bone age:Bone age: epiphyseal closure as determined epiphyseal closure as determined from x-rays; percentage of maturity attained from x-rays; percentage of maturity attained indicates potential for catch-up growth; indicates potential for catch-up growth; hand & hand & the wristthe wrist useful at all ages; also useful at all ages; also leg in early leg in early infancyinfancy

8.8. Growth Velocity (GV)Growth Velocity (GV) Evaluates change in rate of growthEvaluates change in rate of growth More sensitive way of assessing growth More sensitive way of assessing growth

failure or slowed growth failure or slowed growth Formula:Formula:

GV(cm) = GV(cm) = HH22(cm) – H(cm) – H11(cm)(cm) T(yr)T(yr)

wherewhere

HH11 = initial height in centimeters = initial height in centimeters

HH22 = height at next measurement = height at next measurementT T = period between two = period between two

measurements in yearsmeasurements in years

9.9. Body Mass Index (BMI)-for-AgeBody Mass Index (BMI)-for-Age

An effective An effective screening toolscreening tool specific for age specific for age and gender but not a diagnostic tooland gender but not a diagnostic tool

Formula:Formula: Weight(kg)/Height(m Weight(kg)/Height(m22)) BMI-for-age cut-offsBMI-for-age cut-offs

>>9595thth%% OverweightOverweight8585th - th - <95<95thth%% Risk of overweightRisk of overweight<5<5thth%% UnderweightUnderweight

BMI-for-age correlates w/ clinicalBMI-for-age correlates w/ clinicalrisk factors in CVS diseaserisk factors in CVS disease such as such as hyperlipidemia, elevated insulin & hyperlipidemia, elevated insulin & high blood pressure during middle agehigh blood pressure during middle age

Can you Can you seesee risk? risk?

Age = 3 y 3 wks Age = 3 y 3 wks boyboyHeight = 100.8 Height = 100.8 cmcmWeight = 18.6 kgWeight = 18.6 kg

Age = 4 y girlAge = 4 y girlHeight = 99.2 Height = 99.2 cm cm Weight = 17.55 Weight = 17.55 kgkg

Age = 4 y 4 wks Age = 4 y 4 wks girlgirlHeight = 106.4 Height = 106.4 cmcmWeight = 15.7 kgWeight = 15.7 kg

CBMI=18.3 = >95th%Overweight

A BMI=13.9= 10th%Normal

BBMI=17.8= 90th–95th% At risk for overweight

BMI-for-AgeBMI-for-Age

C

A

B

It is easier for a camel It is easier for a camel to pass through the to pass through the eye of a needle if it is eye of a needle if it is lightly greased. lightly greased.

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