Nutritional Requirements throughout the Life Cycle

We need essential amino acids, carbohydrates, essential fatty acids, and an array of vitamins and minerals to sustain life and health. However, nutritional needs vary from one life stage to another. During intrauterine development, infancy, and childhood, for example, recommended intakes of macronutrients and most micronutrients are higher relative to body size, compared with those during adulthood. In elderly persons, some nutrient needs (e.g., vitamin D) increase, while others (e.g., energy and iron) are reduced.

The National Academy of Sciences has published recommendations for Dietary Reference Intakes (DRIs) that are specific for the various stages of life.[1] It should be noted, however, that the DRIs apply to healthy people and are not designed for individuals who are either chronically ill or who are at high risk for illness due to age, genetics, or lifestyle factors (e.g., smoking, alcohol intake, strenuous exercise). Clinicians must make their own judgments regarding nutrient requirements in such cases based on available information (See table).

In this chapter, we will examine nutrient needs throughout the life cycle. Two major themes emerge.

First, the predominant nutritional problem in developed countries is overnutrition, at least regarding energy and macronutrients. Excessive intake has led to unprecedented epidemics of obesity and chronic diseases. Clinicians can assist patients in making the dietary shifts necessary to prevent overnutrition and its sequelae.

Second, a renewed emphasis on vegetables, fruits, whole grains, and legumes can help prevent weight problems and chronic illnesses, including cardiovascular disease, diabetes, and cancer, among others.[2][3],[4],[5],[6],[7],[8] Plant-based diets meet or exceed recommended intakes of most nutrients and have the advantage of being lower in total fat, saturated fat, and cholesterol than typical Western diets, with measurable health benefits.[9],[10] Well-planned plant-based diets are appropriate across the lifespan may help prevent or treat some chronic diseases.[11]

Excess Calorie Intakes: A Risk Factor Common to All Age Groups

The major nutritional problems encountered in developed countries are excess macronutrient intake (especially saturated fat, protein, and sugar) and insufficient intake of the fiber and micronutrients provided by vegetables, fruits, whole grains, and legumes.

Overnutrition begins early. While an expectant mother must provide nutrition for both herself and her developing baby, the increased energy requirements of pregnancy are modest. Typically, pregnant women’s estimated energy requirements are similar to those of nonpregnant women in the first trimester and increase by 340 calories per day in the second trimester and 452 calories per day in the third trimester. Recommended weight gain during pregnancy varies by prepregnancy BMI, with overweight and obese women recommended to gain less weight than underweight or normal weight women.[12] Excess energy intake may result in overly rapid weight gain, conferring a greater risk for labor induction, cesarean section, higher birth weight, and other complications of pregnancy and delivery.[13],[14]

Overfed infants and children may develop dietary habits and perhaps even metabolic characteristics that have lifelong consequences.[15],[16],[17] Infants should be exclusively breastfed for the first 6 months of life if possible. Breastfed infants are less likely to be overweight or obese in childhood and adolescence. At 6 months of age, in addition to breastfeeding, complementary foods should be introduced; parents should avoid both underfeeding and overfeeding.[18] Regarding overfeeding, one meta-analysis of studies on infants aged 3 months – 2 years found that both heavier (“obese”) infants and infants with rapid weight gain were more likely to be obese in childhood, adolescence, and early adulthood.[19] Therefore, caretakers should select foods conducive to healthy body weights and restrain their desire to promote child growth through overfeeding.

Adolescents face a similar problem. Many teens consume higher-than-recommended amounts of fat, saturated fat, sodium, and sugars, thereby increasing the risk for adolescent and adult obesity, among other health problems.[20] The increased prevalence of excess body weight in adolescents is correlated with escalating risk for type 2 diabetes.[21] This does not mean that adolescents are well nourished, however. Despite their higher energy intake, adolescents frequently fail to achieve required intakes of essential micronutrients (e.g., vitamins A and C), and underconsume fiber.[22],[23] This problem is compounded by the fact that roughly 60% of female and more than 25% of male adolescents are dieting to lose weight at any given time, and between 1% and 9% report using maladaptive habits, such as purging, to do so.[24],[25]

Adults in developed countries are at particular risk from excess energy intake. While a significant percentage of North Americans have an inadequate intake of essential micronutrients and fiber, energy intake is typically far in excess of needs.[20],[26] In Western countries, dietary staples (e.g., meat, dairy products, vegetable oils, and sugar) are more energy-dense than in traditional Asian or African cultures, where grains, legumes, and starchy vegetables are larger parts of the diet. This problem is aggravated by increases in food portion sizes and in the availability and consumption of calorie-dense, nutrient-poor fast foods.[27] As a result, adults are experiencing an epidemic of obesity-related diseases, including coronary heart disease, hypertension, diabetes, and cancer. The metabolic syndrome, often triggered by obesity, is a common problem in elderly persons and is associated with greater risk for premature mortality.[28] These circumstances indicate a need for diets that are micronutrient-dense while modest in calories.

Fertility

The role of nutrition in fertility has been the subject of a limited body of research focusing particularly on the role of antioxidants, other micronutrients, and alcohol. However, while nutritional and lifestyle factors may affect fertility directly, they also influence risk for several diseases that impair fertility, including polycystic ovarian syndrome, endometriosis, and uterine fibroids (See relevant chapters).

In females, some studies suggest a potential role for high-dose (750 mg/d) vitamin C and combinations of antioxidants, iron, and arginine supplements in achieving pregnancy.[29] Celiac disease, an immune-mediated condition triggered by gluten, can also impair fertility in women by causing amenorrhea, inducing malabsorption of nutrients needed for organogenesis, and resulting in spontaneous abortion. In affected individuals, fertility may be improved by a gluten-free diet.[30] Obesity is also associated with decreased fertility in women, although being underweight is also problematic: Time to conception doubles with BMI > 35 and quadruples with BMI < 19.[31],[32] Women who may become pregnant should also supplement with 400 mcg/d of folic acid to reduce the risk of neural tube defects, and also ensure adequate vitamin B12 status.[33]

In males, infertility may occur by disruption of the normal equilibrium between the production of reactive oxygen species by semen and oxygen-radical scavengers. This may occur through smoking, infection of the reproductive tract, varicocele, and perhaps through poor diet as well.[34] The result is oxidative damage to sperm. Controlled studies of high-dose combinations of supplementary antioxidants (vitamins C,>200 mg/d; vitamin E, 200 to 600 IU/d; selenium, 100 to 200 μg/d) found improved sperm motility and morphology and increased pregnancy rates, particularly in former smokers.[34] Adequate serum levels of vitamin D are also positively correlated with fertility and sperm motility.[35]

Carnitine is concentrated within the epididymis and contributes directly to the energy supply required by sperm for maturation and motility.[36] Treatment with carnitine or acetylcarnitine (1.0-2.0 g/d) increases the number and motility of sperm and the number of spontaneous pregnancies.[34],[36]

Alcohol consumption is associated with decreased fertility in both women and men.[37],[38] In males, alcohol consumption contributes to impotence and to a reduction of blood testosterone concentrations and impairment of Sertoli cell function and sperm maturation.[38]

Pregnancy and Lactation

Pregnant and lactating women have increased requirements for both macronutrients and micronutrients. The failure to achieve required intakes may increase risk for certain chronic diseases in their children, sometimes manifesting many years later.[16],[17] For instance, studies of the Dutch famine during World War II (in which rations were progressively cut from 1400 cal/d in August 1944 to 1000 cal/d in December, and ultimately to 500 cal/d) found that undernutrition during mid- to late pregnancy increased the risk for glucose intolerance and resulted in greater progression of age-related hypertension.[39] Malnutrition of women during early pregnancy correlated with higher body weights of their offspring as adults, along with increased risk for coronary heart disease and certain central nervous system anomalies.[16],[39],[40]

Protein requirements in pregnancy rise to 1.1 g/kg/d to allow for fetal growth and milk production. The source of protein may be as important as the quantity, however. Some evidence suggests that protein requirements can be more safely met by vegetable than by animal protein. Meat is a major source of saturated fat and cholesterol; it is also a common source of ingestible pathogens and a rich source of arachidonic acid, a precursor of the immunosuppressive eicosanoid PGE2.[41]

Pregnant women also should not meet their increased need for protein by the intake of certain types of fish, such as shark, swordfish, mackerel, and tilefish, which often contain high levels of methylmercury, a potent human neurotoxin that readily crosses the placenta.[42] Other mercury-contaminated fish, including tuna and fish taken from polluted waters (pike, walleye, and bass), should be especially avoided.[43] There is no nutritional requirement for fish or fish oils. Vegetable protein sources, aside from meeting protein needs, can help meet the increased needs for folate, potassium, and magnesium and provide fiber, which can help reduce the constipation that is a common complaint during pregnancy.

Pregnant and/or lactating women also require increased amounts of vitamins A, C, E, and certain B vitamins (thiamine, riboflavin, niacin, pyridoxine, choline, cobalamin, and folate). Folate intake is especially important in early pregnancy for the prevention of neural tube defects and should be consumed in adequate amounts prior to conception; evidence shows that average intakes are only~60% of current recommendations.[44] Folate intakes were noted to be poorest in women eating a typical Western diet and highest in women eating vegetarian diets.[45] Regardless of folate consumed from food sources, women capable of becoming pregnant are recommended to take 400 mcg/d of folic acid to reduce the risk of neural tube defects.[33]

Pregnant women also require increased amounts of calcium, phosphorus, magnesium, iron, zinc, potassium, selenium, copper, chromium, manganese, and molybdenum.[1] Prenatal vitamin-mineral formulas are suggested to increase the likelihood that these nutrient needs will be met.

Infancy and Early Childhood

Requirements for macronutrients and micronutrients are higher on a per-kilogram basis during infancy and childhood than at any other developmental stage. These needs are influenced by the rapid cell division occurring during growth, which requires protein, energy, and nutrients involved in DNA synthesis and metabolism of protein, calories, and fat. Increased needs for these nutrients are reflected in DRIs for these age groups, some of which are briefly discussed below.[1]

Energy. While most adults require 25 to 30 calories per kg, a 4-kg infant requires more than 100 cals/kg (430 calories/day). Infants 4 to 6 months who weigh 6 kg require roughly 82 cals/kg (490 calories/day). Energy needs remain high through the early years. Children 1 to 3 years of age require approximately 83 cals/kg (990 cals/d). Energy requirements decline thereafter and are based on weight, height, and physical activity.

As an energy source, breast milk offers significant advantages over manufactured formula. Breastfeeding is associated with reduced risk for obesity, allergies, hypertension, and type 1 diabetes; improved cognitive development; and decreased incidence and severity of infections.[46] It is also less costly than formula feeding.[47],[48]

The American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life, followed by continued breastfeeding as complementary foods are introduced. Breastfeeding may continue for 1 year or longer.[49] Parents often introduce solid foods to their infants before 6 months, of even before 4 months of age.[50] Parents should be encouraged to delay introduction of solid foods until 6 months of age to all for optimal infant nutrition, growth and development.

Protein. Older infants, aged 7-12 months, have a Recommended Daily Allowance (RDA) for protein of 1.2 g/kg/d, or 11 g/d of protein. Children aged 1–3 years have an RDA of 1.05 g/kg/d or 13 g/d of protein and children aged 4–8 years have an RDA of 0.95 g/kg/d or 19 g/d of protein.[51]

Water. Total water requirements (from beverages and foods) are also higher in infants and children than for adults. Children have larger body surface area per unit of body weight and a reduced capacity for sweating when compared with adults, and therefore are at greater risk of morbidity and mortality from dehydration.[52] Parents may underestimate these fluid needs, especially if infants and children are experiencing fever, diarrhea, or exposure to extreme temperatures (e.g., in vehicles during summer).

Essential fatty acids. Requirements for fatty acids on a per-kilogram basis are higher in infants than adults (see below). Through desaturation and elongation, linolenic and alpha-linolenic acids are converted to long-chain fatty acids (arachidonic and docosahexanoic acids) that play key roles in the central nervous system. Since both saturated fats and trans fatty acids inhibit these pathways, infants and children should not ingest foods that contain a predominance of these fats.[53]

Adolescence and Adulthood

The Institute of Medicine recommends higher intakes of protein and energy in the adolescent population for growth. For most micronutrients, recommendations are the same as for adults. Exceptions are made for certain minerals needed for bone growth (e.g., calcium and phosphorus).[54] However, these recommendations are controversial, given the lack of evidence that higher intakes are an absolute requirement for bone growth. Evidence is clearer that bone calcium accretion increases as a result of exercise rather than from increases in calcium intake.[55]

Micronutrient needs in adults 19 to 50 years of age differ slightly according to gender. Males require more vitamin C, K, B1, B2, and B3; choline; magnesium; zinc; chromium; and manganese. Menstruating females require more iron, compared with males of similar age.

Later Years

Due to reductions in lean body mass, metabolic rate, and physical activity, elderly persons require less energy than younger individuals need. Some DRIs for elderly persons differ from those of younger adults. For example, in order to reduce the risk for age-related bone loss and fracture, the DRI for vitamin D is increased from 600 IU/d in individuals 19-70 years of age to 800 IU/d for those > 70 years of age.[56] Suggested iron intakes drop from 18 mg per day in women ages 19-50 to 8 mg/d after age 50, due to iron conservation and decreased losses in postmenopausal women, compared with younger women.[1] Although diets that are modest in protein have been associated with health benefits, including reductions in diabetes and cancer incidence and overall mortality for people aged 65 and under, for those over aged 65, it remains important to ensure adequate protein intake for older people.[57] Plant sources of protein are preferable.

Some elderly persons have difficulty getting adequate nutrition because of age- or disease-related impairments in chewing, swallowing, digesting, and absorbing nutrients.[58] Nutrient status may also be affected by decreased production of digestive enzymes, senescent changes in the cells of the bowel surface, and drug-nutrient interactions (see Micronutrients chapter).[58] The results can be far-reaching. For example, a study in elderly long-term-care residents demonstrated frequent deficiency in selenium, a mineral important for immune function.[58] In turn, impaired immune function affects susceptibility to infections and malignancies. The role of vitamin B6 in immunity also presents a rationale for higher recommended intakes for elderly persons.[59] Approximately 10-30% of older adults are commonly affected by atrophic gastritis, which can interfere with absorption of vitamin B12. Consequently, the Institute of Medicine recommends that all adults over age 50 get the majority of their vitamin B12 from a supplement or fortified foods. Note that intakes well above the RDA may be required in older adults to maintain vitamin B12 status.[60]

Nutritional interventions should first emphasize healthful foods, with supplements playing a judicious secondary role. Although modest supplementary doses of micronutrients can both prevent deficiency and support immune function (see Upper Respiratory Infection chapter), overzealous supplementation (e.g., high-dose zinc) may have the opposite effect and result in immunosuppression.[61] Multiple vitamin-mineral supplements have not been consistently shown to reduce the incidence of infection in elderly individuals.[62] The effects of multiple vitamin-mineral supplementation on cancer risk may be mixed, with some studies showing benefit and others showing increased cancer risk related to supplement use (e.g., increased risk for prostate cancer and non-Hodgkin lymphoma in women).[63],[64],[65] Risks may be specific to certain nutrients. For example, high calcium intake has been associated with prostate cancer risk (see Prostate Cancer chapter), while other micronutrients have protective effects.

Alcohol intake can be a serious problem in elderly persons. The hazards of excess alcohol intake include sleep disorders, problematic interactions with medications, loss of nutrients, and a greater risk for dehydration, particularly in those who take diuretics. Roughly one-third of elderly persons who overuse or abuse alcohol first develop drinking problems after the age of 60 years.[66]

It goes without saying that recommendations regarding nutritional interventions in elderly patients should take patients’ wishes into account, particularly when a limited lifespan reduces the expected benefit of an intervention.

Conclusion

Requirements for energy and micronutrients change throughout the life cycle. Although inadequate intake of certain micronutrients is a concern, far greater problems come from the dietary excesses of energy, saturated fat, cholesterol, and refined carbohydrate, which are fueling the current epidemics of obesity and chronic disease. Clinicians can assist patients in choosing foods that keep energy intake within reasonable bounds, while maximizing intakes of nutrient-rich foods, particularly vegetables, fruits, legumes, and whole grains.

Life Stage

Change in Nutrient Needs

Changing Nutrient Needs Through the Life Cycle

Pregnancy*

Increased requirements: energy, protein, essential fatty acids, vitamin A, vitamin C, B-vitamins (B1, B2, B3, B5, B6, B12, folate, choline) & calcium, phosphorus,** magnesium, potassium, iron, zinc, copper, chromium, selenium, iodine, manganese, molybdenum

Lactation*

Increased requirements: vitamins A, C, E, all B-vitamins, sodium, magnesium**

Decreased requirements: iron

Infancy, childhood*

Increased requirements: energy, protein, essential fatty acids

Adolescence*

Increased requirements: energy, protein, calcium, phosphorus, magnesium, zinc (females only)

Early adulthood (ages 19-50)

Increased requirements for males, compared with females: vitamins C, K; B1, B2, B3, and choline; magnesium, zinc, chromium, manganese

Increased requirements for females, compared with males: iron

Middle age (ages 51-70)*

Increased requirements: vitamin B6, vitamin D

Elderly (age 70+)*

Increased requirements: vitamin D
Decreased requirements: energy; iron (females only)

* Relative to adult requirements for those 19-50 years of age (and on a per-kg basis for macronutrients).

** Applies only to individuals under age 18.

For detailed nutrient recommendations, see Macronutrients and Micronutrients chapters.

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