According to World Health Organisation, most developed countries have accepted the chronological age of 65 years as definition of old age1. This increase in average human life span from 40-45 years to nearly 75 years in most of the industrialised countries can be attributed to improved medical systems, better standards of living and balanced nutrition. However, successful ageing is not defined by longevity alone, but also by well-being in various aspects of life which include social, physical and mental health. The process of ageing brings about physiological, psychological and immunological changes which influences the nutritional status. As dieticians, our goal for geriatric population should focus on providing good nutrition with modified food habits which align with their physiological changes and help them build better immunity and resistance to diseases. This will enable them achieve healthy and independent living.
To perceive their nutritional requirements, it is necessary to comprehend the physiological changes occurring as a person advances in life. Some of these changes 2 are:
| Heart | Cardiac output decreases linearly after the third decade by the rate of 1 percent per year. Also, after the age of 70 years, amyloid deposits in the myocardium increase which can result in development of congestive heart failure. |
| Hypertension | Studies have found that as the age advances, there is a progressive increase in blood pressure. It is also reported that over 50% of those over 65 years are hypertensive. |
| Coronary Artery Disease (CAD) | Thickening of wall, collagenisation and accumulation of calcium and phosphate in elastic fibres have been found to increase with age, all leading to arteriosclerosis and CAD. |
| Lungs | Vital capacity of the lungs decreases progressively as age advances. Geriatrics also have a pronounced increase in the incidences of pneumonia and other lung infections due to decreased flow of saliva, poor oral hygiene and higher rate of colonization of bacteria as compared to young people. |
| Kidneys | With increase in age, there is a decrease in creatinine concentration due to a reduction in muscle cell mass. This also parallels the decrease in glomerular filtration rate. It is found that both the concentration and dilution abilities of the kidneys deteriorate with age. |
| Osteoporosis | After the age of 40 years, there is a linear decline in bone mass at the rate of 10% per decade for women and 5% per decade for men. By the age of 80 years, around 30-50% skeletal mass may be lost. |
| Menopause | Several protective factors of ovarian function in conditions like osteoporosis, maintenance of the ratio between high density lipoprotein to low density lipoprotein, oestrogen activity etc. are lost in post-menopausal women |
| Muscle | There is age related decline in lean body mass which is primarily due to loss and atrophy of muscles. |
| Digestive tract | Since the movement of food slows down with age, due to decreased peristaltic movement, there are higher chances of constipation. Development of polyps and prevalence of GERD and diverticular diseases is also commonly seen in the aged. |
| Mouth | Chewing problems associated with tooth loss and dentures can also interfere with taste sensations, along with the reduction in saliva production. |
Nutrient Requirements
Energy:
After the age of 35 years, the basal metabolic rate of an individual reduces due to decreased muscle mass. This is often accompanied by reduced physical activity leading to a drop in energy requirements. Lean body mass declines up to 2-3% per 10 years and the average fat percent in the body increases from 15 to 25% per 10 years.Thus, the calorie intake has to be adjusted to maintain appropriate body weight.
Below are the energy requirements (kcal / 24hrs) of adults with different activity levels as per guidelines on Nutrient requirement and recommended Dietary allowance for Indians, ICMR, 2010. 3
| Gender | Activity Level | Body weight (Kg) | Energy requirment |
| Male | Sedentary | 60 | 2320 |
| Female | Sedentary | 55 | 1900 |
Proteins:
According to a study titled ‘Protein Requirements in the Elderly’ in the International Journal of Vitamin and Nutrition Research, 2011, adequate protein intake and the maintenance of nitrogen equilibrium are of particular importance in the elderly because this age group is at increased risk of illness and malnutrition4.
With age, the skeletal muscle mass reduces. This reduction results in decrease in store of protein provided by skeletal muscle and may be insufficient to meet the demands of protein synthesis. Hence, increased dietary protein intake is extremely necessary to meet the increased needs.
According to Food and Nutrition Board, Institute of Medicine, National Academies (2011), people aged 50 years and above require 0.66g/kg/d, but due to decreased appetite and poor digestion, geriatrics might not be able to fulfil the demands by diet alone. Strategies of incorporating proteins in various ways in their diets, and supplementing when necessary can be considered5. Another study from Journal of the American College of Nutrition states that a decrease in skeletal muscle is the most noticeable manifestation of the change in their body composition but there is also a reduction in other physiologic proteins such as organ tissue, blood components, and immune bodies as well as declines in total body potassium and water. This contributes to impaired wound healing, loss of skin elasticity, and an inability to fight infection6.Hence, explaining the increased demands of proteins during this phase. B. Srilakshmi, 2009, suggests that of total caloric intake, 11-12% should be from proteins7.
Carbohydrates:
Considering the fact that many old patients suffer from impaired glucose tolerance and diabetes mellitus, there is a greater possibility of them getting into hypoglycaemia (due to oral hypoglycaemic agents) or hyperglycaemia often. Emphasis should be placed on providing the elderly with complex carbohydrates and on controlling the amount of simple sugars in their diet. The Archives of Gerontology and Geriartics states that fiber intake is also very important in particular in the elderly, and therefore more fruits and vegetables should be a part of their diet8.It is necessary that at least 50% of calories should come from carbohydrates alone.
Fats:
According to the World Health Organisation (2015), degenerative diseases such as cardiovascular and cerebrovascular disease, diabetes, osteoporosis and cancer, which are among the most common diseases affecting older persons, are all diet-influenced 9. Dietary fat seems to be associated with cancer of the colon, pancreas and prostate. It also has a role to play in development of cardiovascular risk factors and the disease itself. Asians are more likely to develop lifestyle diseases. Cholesterol problems are very common among South Asians due to genetic risk, lack of physical activity, and suboptimal dietary habits10. To combat these issues, here are some latest recommendations by renowned bodies:
- American Heart Association suggests reducing saturated fat to no more than 5 to 6 percent of total calories. For someone eating 2,000 calories a day that’s about 11 to 13 grams of saturated fat. It also emphasises on reducing the percent of calories from trans-fat11.
- The latest recommendation by the USDA states limiting dietary cholesterol to 300 milligrams a day12.
- The Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services recommends getting between 20% and 35% of calories from total fat, with most fats coming from fish, nuts, and vegetable oils 13.
Micronutrients:
| Nutrient | RDA | Rationale |
|---|---|---|
| Calcium | Females (51-70y): 1000mg Males (51-70y): 800mg14 | Elderly, especially women over 50 years, require more calcium during this phase. This is so because of decline in oestrogen after menopause and there are increased losses resulting in demineralization of bone and osteoporosis. |
| Iron | Men: 17 mg/d Women: 21 mg/d | Iron deficiency in the elderly almost always results from blood loss. Because iron is present in many metabolic processes besides the production of haemoglobin, iron deficiency leads to a variety of defects which are manifested at biochemical, tissue, and functional levels. Iron is a component of several enzymes in the respiratory electron transport chain. Adequate haeme and iron levels are also necessary to control cytoplasmic and mitochondrial protein synthesis. Iron deficiency results in tissue defects, including those affecting the gastrointestinal tract, and defects of mitochondria and lymphocytes 15. Normal iron levels seem to be necessary for normal work capacity. Elderly patients complaining of increased fatigue should therefore be screened for iron deficiency. Greater emphasis should also be placed upon green leafy vegetables like cauliflower greens, agathi,methi,dill(shepu)etc., whole grains, rajma, bajra, nachni to improve iron intake. Along with this, overall protein and Vitamin C intake should be increased to enhance absorption. |
| Zinc | Males (51-70y): 9.4 mg/d Females (51-70y): 6.8 mg/d | Zinc acts like an antioxidant, protecting cells from damage by harmful free radicals, which increases the risk of chronic conditions. Zinc deficiency is frequent in the elderly and leads to changes similar to those that occur in oxidative inflammatory aging and immunosenescence.16 |
| Vitamin D | Both males and females (51-70y): 10 mcg/d | Elderly in particular are more prone to Vitamin D deficiency since there is decreased exposure to sunlight and reduced renal mass. In order to prevent bone fractures and improve bone mineral density, supplementation of Calcium with Vitamin D should be considered. They should also be encouraged to walk for a few minutes every day to keep their bones healthy, or expose themselves for 20-30 minutes to sunlight. |
| Vitamin C | Males: 75 mg/d Females: 60 mg/d | With increase in age, stress, catabolism and some medications, the requirement of Vitamin C goes up. Also, the need increases to prevent onset of macular degeneration and cataract- two of the most common eye related issues geriatric population face. |
| Vitamin B6 | Males (51-70y): 1.4 mg/d Females (51-70y): 1.3 mg/d | Many old patients suffer from atrophic gastritis which often interferes with absorption of Vitamin B6. If they suffer from any kind of liver ailment or are alcoholic, their requirement of Vitamin B6 goes even higher. It also has a prominent role in maintaining the immune system and hence has to be included actively in their diet. |
| Vitamin B12 | Both males and females (51-70y): 2 mcg/d | Absorption of protein-bound vitamin B12 is decreased in the elderly, owing to a high prevalence of atrophic gastritis in this age group. Atrophic gastritis results in a low acid-pepsin secretion by the gastric mucosa, which in turn results in a reduced release of free vitamin B12 from food proteins. Furthermore, hypochlorhydria in atrophic gastritis results in bacterial overgrowth of the stomach and small intestine, and these bacteria may bind vitamin B12 for their own use17. Hence, most old aged are found to be deficient in Vitamin B12. |
Methods of Assessment of Nutritional Status :
Apart from Body Mass Index, there are a few tools designed for the elderly. They are:
- Mini Nutritional Assessment (MNA) :
The MNA evaluates the risk of malnutrition in the elderly when they are admitted to a hospital or a nursing home. It consists of a general health assessment, a dietetic assessment, anthropometric measurements, the patient’s subjective assessment, and global evaluation. Global evaluation includes questions on living independently, prescription drug use, psychological stress, acute disease, mobility, dementia, and skin conditions. - Nutritional Screening Initiative (NSI) :
The NSI incorporates screening and assessment at three levels. It includes dietary assessment, general assessment and social assessment questions which helps in understanding the warning signs of poor nutritional status in the elderly18.
Dietary Recommendations
- Food for the elderly has to be modified physically to suit their medical conditions. It has to be soft, chewable and easily digestible.
- They also have to be provided with plenty of fluids to prevent constipation and dehydration. One of the studies titled ‘Fluid intake in the institutionalized elderly’ for calculating the amount of water required by old patients” in Journal of American Dietetic Association recommends a formula which is: 1500 ml per day plus 15ml fluid per kg to be added for the actual weight minus 20 kg19.
- Smoking or overconsumption of alcohol leads to reduced absorption of nutrient associated diseases. Hence, they should be counselled to reduce smoking and alcohol consumption.
- To favour complete digestion and avoid gastric complications, small and frequent meals have to be given.
- If the person is suffering from insomnia, coffee, tea and cola beverages have to be reduced since they cause stimulation and will hinder sound sleep. They can be given warm milk before going to bed to induce peaceful sleep.
- Intake of green leafy vegetables and fruits have to be encouraged as they are a good source of carotene, calcium, iron, riboflavin, folic acid, vitamin C, fibre and antioxidants.
- Some superfoods for the elderly are:
- Sweet potatoes: They are densely packed with nutrients and thus make a good option for those who have low appetite. They contain Vitamin A, C, E and minerals that are known for their immune enhancing and disease preventing properties. They can be steamed and be softened to suit the chewing disabilities seen in the seniors.
- Garlic: Garlic is known for its antibiotic and anti-inflammatory properties and they are nature’s best immune boosters. They can easily be added to many dishes and thus make a good superfood.
- Broccoli: Broccoli is blessed with various nutrients like fiber, antioxidants and vitamins such as A, C, B9 (folate) and K. It not only keeps the eyes, red blood cells, immune system healthy but also the bones and tissues benefit from this vegetable. Broccoli falls under the cruciferous category and is known to fight against certain cancers, including liver, breast, prostate and colon cancers.
- Green tea: It is abundant in antioxidants which is known to reduce the risk of certain cancers such as those affecting the bladder, prostate, breast, stomach, and blood. It helps to reduce the risk of diabetes and depression and inflammation among patients with arthritis. It also improves brain function and has anti-aging properties.
- Fishes: Fishes are rich in omega 3 which has anti-inflammatory properties and help to reduce the risk of arthritis, heart disease, and cancer.
- Health Statistics and Information Systems, World Health Organisation. Retrieved from http://www.who.int/healthinfo/survey/ageingdefnolder/en/
- Boss, G. R., &Seegmiller, J. E. Age-Related Physiological Changes and Their Clinical Significance. West J Med. 1981 Dec; 135(6): 434–440
- Nutrient Requirements and Recommended Dietary Allowance for Indians, Indian Council of Medical Research. 2010
- Volkert D, Seiber CC. Protein Requirements in the Elderly. Int J VitamNutr Res. 2011 Mar;81(2-3):109-19
- Recommendations by United States Department of Agriculture, Food and Nutrition Information Centre
- Chernoff R. Proteins and Older Adults. J Am Coll Nutr. 2004 Dec; 23:627S-630S
- B. Srilakshmi. Dietetics, 2009; 79-87
- Donini LM, Savina C Et al. Nutrition in the Elderly: Role of Fibre. Arch GerontolGeriatr. 2009;49(1):61-9
- Ageing. World Health Organisation
- Cholesterol and South Asians. Indian Heart Association. Retrieved from http://indianheartassociation.org/cholesterol-and-south-asians
- Know your Fats. American Heart Association.
- Scientific Report of the 2015 Advisory Committee. USDA
- Older Adults Health Facts. Guidelines by US Department of Health and Human Services
- Recommendations by Food and Nutrition Board, Institute of Medicine, National Academies
- Schultz BM, Freedman ML. Iron Deficiency in the Elderly, BaillieresClinHaematol. 1987 Jun;1(2):291-31
- Angel JR. Zinc, Aging, and Immunosenescence: an overview. Pathobiol Aging Age Relat Dis. 2015; 5:10.3402
- Baik HW, Russell RM.Vitamin B12 deficiency in the elderly.Annu Rev Nutr. 1999;19:357-77
- Methods of Assessment of Nutritional Status, Old Age Solutions, All India Institute of Medical Sciences
- Chidester JC, Spangler AA.Fluid intake in the institutionalized elderly.J Am Diet Assoc. 1997 Jan;97(1):23-8
This article is contributed by Nurture Health Solutions
The nutritional link between the mother and the child continues even after birth. The new-born depends solely on breast milk for nourishment for a few months and so it is extremely crucial for the growth of the infant. This milk contains hundreds to thousands of distinct bioactive molecules which protect the infant against infection and inflammation and contribute to immune maturation, organ development, and healthy microbial colonization. Also, a lot of physiological changes occur in the mother post-delivery. This phase is also known as puerperium, and the changes occurring in this phase include chills, afterbirth pains, lochia- which is a form of bloody discharge from the vagina), difficulty in urinating and passing stools, sore muscles, breast changes etc. and hence an alteration in diet becomes vital1.
- Energy: Exclusive breastfeeding is recommended for the first six months after delivery, with introduction of complementary foods and continued breastfeeding thereafter (WHO, 2001) 2. According to the Food and Agriculture Organisation, the energy requirement of a lactating woman is defined as the level of energy intake from food that will balance the energy expenditure needed to maintain a body weight and body composition, a level of physical activity and breastmilk production that are consistent with good health for the woman and her child, and that will allow economically necessary and socially desirable activities to be performed3. To operationalize this definition, the energy needed to produce an appropriate volume of milk must be added to the woman’s habitual energy requirement, assuming that she resumes her usual level of physical activity soon after giving birth. The ICMR recommends energy increase of 600 Kcal for the first six months and 520 Kcals for the next six months .
- Carbohydrates: The principal carbohydrate in human milk is lactose, a disaccharide that contains galactose joined by beta-linkage to glucose. In human milk, lactose is present in the average concentration of 70g/litre and it is second only to water as a major constituent. Compared with glucose, lactose provides twice the energy value per molecule. For the first six months of life, exclusive breast feeding is recommended .This time tailors the concentration of lactose to the maturing neonatal and infant gut, particularly while colonic microflora and pancreatic amylase production are developing. Hence mothers need to focus on having a combination of simple and complex carbohydrates while they are lactating, emphasising more on complex carbohydrates. Carbohydrates should make up for 55% of total calories, with a minimum of 100g/dayfor lactating mother. Their diet should also include 25g of dietary fibre/day. Insoluble fibre prevents fluctuating blood sugars and soluble fibre cures constipation and heartburn which is common after delivery. 5
Good sources: For a good combination of soluble and insoluble fibre, lactating mothers need to consume whole grain cereals, pulses, dals, vegetables, roots and tubers and fruits regularly. - Proteins: Protein needs are high during lactation both for the mother and the infant. Large amount of amino acids is needed by the new-born for the formation of new muscle, connective tissue and bone, and for synthesis of a numerous enzymes and hormones. Lactating mothers also need protein to recover from the physiological strain of pregnancy and childbirth. The ICMR (2010) recommends an additional 19 g/day to be safe allowance for a lactating woman during 0-6 months and an additional 13g/day for 6-12 months over and above the basic 1g/kg body weight4. It is also recommended that around 12-13% of total calories should come from proteins3.
Good sources: Eggs, lean meat, fish, milk and milk products, pulses, soybean, nuts. - Fats: During lactation, about one third of the fatty acids present in the milk are derived directly from the maternal diet. Although, the total amount of fat in breast milk is not influenced by mother’s diet, the composition of breast milk fat reflects the composition of the mother’s diet6. Hence it’s important to incorporate essential fatty acids like ALA, DHA, EPA in her daily dietary consumption. ICMR (2010) recommends 30g/day of visible fat for lactating mothers, which is around 10-12% of her total calorie intake.4
Good sources: Sources of Alpha linolenic acid (ALA) include vegetarian foods like flaxseeds, flaxseed oil, canola oil, soya beans, pumpkin seeds, walnuts, chia seeds etc.
Sources of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) include non-vegetarian foods like fatty fish (salmon, mackerel, tuna), fish oils, enriched eggs. Some algae and seaweed are vegetarian sources of DHA available in form of capsules.
Other Nutrients :
Nutrient | Recommendation | Rationale | Sources |
| Calcium | 1200mg/d | During lactation, there is daily secretion of calcium into the breastmilk which comes to about 10g per month7. If extra calcium is not consumed to meet the additional requirement, during 8 months of breastfeeding around 7% of calcium will be leached from the bones and used for milk production. | Milk and milk products, Ragi(nachni), seafood (with bones), tofu, beans, dark green leafy veg, sesame seeds, cauliflower greens, rajgira, horse gram etc. |
| Iron | 21 mg/d | The baby is born with large reserve of iron as mother’s milk is not a good source of iron.During lactation, mother needs iron to compensate the loss occurring for production of milk. However due to amenorrhea, the iron requirement is compensated for and it remains the same as that of general population. However, if iron requirements are not being met with diet alone, supplementation becomes necessary. 8 | Bajra, garden cress seeds, dill (shepu/suva), lentils, tofu, soybean, dates, egg yolk etc |
| Vitamin A | 7600 mcg/d | The additional needs during lactation are calculated on the basis of Vitamin A secreted in the breastmilk and also, keeping in mind the requirement of infants aged below 6 months. | Liver, egg yolk, red and orange fruits and vegetables, green leafy vegetables |
| Vitamin C | 80 mg/d | The additional needs are calculated based on Vitamin C secreted in the breastmilk. The quantity of Vitamin C in 650ml of milk is about 3mg/dl and thus ICMR recommends additional 20 mg which makes it 80 mg per day during lactation. | Amla, guava, agathi, cabbage, coriander leaves, drumstick leaves, knol-khol greens, giant chillies (capsicum) green chillies |
| Vitamin D | - | Vitamin D deficiency is common and can lead to abnormal bone growth. Supplementing the mother is essential to prevent deficiency both in the lactating mother and the infant. It is suggested that both the mother and the baby get some exposure to the sunlight daily. 9 The requirements of Vitamin D don’t change during lactation; however, ICMR recommends that if there is not enough exposure to sunlight, supplementing with 400 IU of Vitamin D daily is crucial. 4 | Exposure to sunlight, liver, fortified butter, fortified milk and other fortified foods. |
| Water | A minimum of 8 glasses/day | An increased intake of fluids is necessary for adequate milk production, since milk is a fluid. Water and beverages such as milk, coconut water and other liquids all add to the fluid necessary to produce milk.10 | - |
Galactagogues
Galactagogues are substances that stimulate milk production or milk supply. They are broadly classified into two types based on their origin and functioning:
1. Synthetic galactagogues and
2. Herbal galactagogues
Synthetic galactagogues: Galactagogues are medications that aid in initiating and maintaining adequate milk production. Most exert their pharmacologic effects through interactions with dopamine receptors, resulting in increased prolactin levels and thereby augmenting milk supply. Some examples of synthetic galactagogues are domperidone and metoclopramide.
Herbal galactagogues: Herbs and foods that have been observed to increase milk production are collectively known as herbal galactagogues.
Some of the examples include:
Dietary Recommendations
Recommended Dietary Allowance for Lactation (ICMR, 2010)
| RDA for a non-lactating woman | 0-6 months | 6-12 months | |
| Energy (Kcal/d) | Sedentary work- 1900, Moderate work- 2230, Heavy work- 2850 | +650 | +520 |
| Protein (g/d) | 55 | 74 | 68 |
| Visible Fat (g/d) | Sedentary work-20, Moderate work-25, Heavy work-30 | 30 | 30 |
| Calcium (mg/d) | 600 | 1200 | 1200 |
| Iron (mg/d) | 21 | 21 | 21 |
| Zinc (mg/d) | 10 | 12 | 12 |
| Magnesium (mg/d) | 310 | 310 | 310 |
| Vitamin A (Retinol) (mcg/d) | 600 | 950 | 950 |
| Vitamin A (B- Carotene) (mcg/d) | 4800 | 7600 | 7600 |
| Thiamine (mg/d) | Sedentary work- 1.0, Moderate work- 1.1, Heavy work- 1.4 | +0.3 | +0.2 |
| Riboflavin (mg/d) | Sedentary work- 1.1, Moderate work- 1.3, Heavy work- 1.7 | +0.4 | +0.3 |
| Niacin Equivalent (mg/d) | Sedentary work-12, Moderate work-14, Heavy work-16 | +4 | +3 |
| Vitamin B6 (mg/d) | 2.0 | 2.5 | 2.5 |
| Ascorbic acid (mg/d) | 40 | 80 | 80 |
| Dietary folate (mcg/d) | 200 | 300 | 300 |
| Vitamin B12 (mcg/d) | 1.0 | 1.5 | 1.5 |
The nutritional link between the mother and the child continues even after birth. The new-born depends solely on breast milk for nourishment for a few months and so it is extremely crucial for the growth of the infant. This milk contains hundreds to thousands of distinct bioactive molecules which protect the infant against infection and inflammation and contribute to immune maturation, organ development, and healthy microbial colonization. Also, a lot of physiological changes occur in the mother post-delivery. This phase is also known as puerperium, and the changes occurring in this phase include chills, afterbirth pains, lochia- which is a form of bloody discharge from the vagina), difficulty in urinating and passing stools, sore muscles, breast changes etc. and hence an alteration in diet becomes vital1.
Energy: Exclusive breastfeeding is recommended for the first six months after delivery, with introduction of complementary foods and continued breastfeeding thereafter (WHO, 2001) 2. According to the Food and Agriculture Organisation, the energy requirement of a lactating woman is defined as the level of energy intake from food that will balance the energy expenditure needed to maintain a body weight and body composition, a level of physical activity and breastmilk production that are consistent with good health for the woman and her child, and that will allow economically necessary and socially desirable activities to be performed3. To operationalize this definition, the energy needed to produce an appropriate volume of milk must be added to the woman’s habitual energy requirement, assuming that she resumes her usual level of physical activity soon after giving birth. The ICMR recommends energy increase of 600 Kcal for the first six months and 520 Kcals for the next six months .
Carbohydrates: The principal carbohydrate in human milk is lactose, a disaccharide that contains galactose joined by beta-linkage to glucose. In human milk, lactose is present in the average concentration of 70g/litre and it is second only to water as a major constituent. Compared with glucose, lactose provides twice the energy value per molecule. For the first six months of life, exclusive breast feeding is recommended .This time tailors the concentration of lactose to the maturing neonatal and infant gut, particularly while colonic microflora and pancreatic amylase production are developing. Hence mothers need to focus on having a combination of simple and complex carbohydrates while they are lactating, emphasising more on complex carbohydrates. Carbohydrates should make up for 55% of total calories, with a minimum of 100g/dayfor lactating mother. Their diet should also include 25g of dietary fibre/day. Insoluble fibre prevents fluctuating blood sugars and soluble fibre cures constipation and heartburn which is common after delivery. 5
Good sources: For a good combination of soluble and insoluble fibre, lactating mothers need to consume whole grain cereals, pulses, dals, vegetables, roots and tubers and fruits regularly.
Proteins: Protein needs are high during lactation both for the mother and the infant. Large amount of amino acids is needed by the new-born for the formation of new muscle, connective tissue and bone, and for synthesis of a numerous enzymes and hormones. Lactating mothers also need protein to recover from the physiological strain of pregnancy and childbirth. The ICMR (2010) recommends an additional 19 g/day to be safe allowance for a lactating woman during 0-6 months and an additional 13g/day for 6-12 months over and above the basic 1g/kg body weight4. It is also recommended that around 12-13% of total calories should come from proteins3.
Good sources: Eggs, lean meat, fish, milk and milk products, pulses, soybean, nuts.
Fats: During lactation, about one third of the fatty acids present in the milk are derived directly from the maternal diet. Although, the total amount of fat in breast milk is not influenced by mother’s diet, the composition of breast milk fat reflects the composition of the mother’s diet6. Hence it’s important to incorporate essential fatty acids like ALA, DHA, EPA in her daily dietary consumption. ICMR (2010) recommends 30g/day of visible fat for lactating mothers, which is around 10-12% of her total calorie intake.4
Good sources: Sources of Alpha linolenic acid (ALA) include vegetarian foods like flaxseeds, flaxseed oil, canola oil, soya beans, pumpkin seeds, walnuts, chia seeds etc.
Sources of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) include non-vegetarian foods like fatty fish (salmon, mackerel, tuna), fish oils, enriched eggs. Some algae and seaweed are vegetarian sources of DHA available in form of capsules.
Shatavari: Although researches and literatures fail to elaborate on benefits on herbal galactagogues, they have been used traditionally and are widely popular. Shatavari is taken by many Asian mothers as a plant extract or in powder form as it is believed to increase milk production.
Garlic
Garlic has been traditionally used as a galactagogue. Studies have shown that babies fed on breastmilk of garlic eating mothers stayed fed longer and the production of milk was relatively higher. Additionally it also relieves the mother and the baby of gastrointestinal problems and enhances their immunity.
Fenugreek seeds: Fenugreek seeds are most widely used herbal galactagogues, globally. This herb has been shown to increase breast milk production significantly.
Promote exclusive breastfeeding for the first six months and encourage breastfeeding till two years or as long as one can.
Colostrum, the yellow milk which is secreted in the first 2 days of delivery, is rich in nutrients and anti-infective factors and should be fed to infants.
Exercising regularly and remaining physically active helps in maintaining ideal body weight. Breastfeeding is the best way to reduce post-partum weight gain and also reduces the possibility of infections.11
Increase water intake. It is important to have a glass of water each time the mother feeds the baby.
Avoid caffeine and sugar since it is secreted in the milk and can agitate the baby, make him restless and cause disturbed sleep. Sugar can also contribute to weight gain both in the mother and the baby.
Small and frequent meals should be consumed and they should include all the food groups in proper proportions.
Avoid tobacco (smoking and chewing), alcohol and drugs during lactation. There are numerous studies which highlight the impact of nicotine and alcohol consumption on the infant’s health and development. Some of the effects are:
a. Nicotine: Nicotine causes fussy behaviour, breast refusal, excessive crying, and increased colic in mothers. It increases baby’s heart rate, risk of SIDS by affecting the way a baby can resuscitate during hypoxic episodes and interferes with normal infant lung development. 12, 13
b. Alcohol: Alcohol consumption affects milk production. Furthermore, some of the alcohol consumed by a lactating woman is transferred to her milk and thus consumed by the infant. This alcohol consumption may adversely affect the infant’s sleep and gross motor development and also influence early learning. 14
Superfoods like these can be given to lactating mothers:
Almonds
Almonds are packed with proteins-a nutrient nursing mothers require in abundance. They also contain various other nutrients like Vitamin B, Vitamin E, Copper, Magnesium, Zinc which all help in strengthening the new-born’s immunity and also enhance the pace of mother’s recovery post-delivery 15. It works efficiently to deal with post-partum depression and induces peaceful sleep in the baby.
Milk and Milk Products
Milk itself and its derivatives like yogurt, cheese, paneer etc. deliver a boost of bone-strengthening Vitamin D along with Calcium. They are also packed with protein and Vitamin B complex, which help in cell formation and energy release.
Daily meal plan for breastfeeding mothers:
| Food Group | Amount | Examples |
| Cereals | 8-9 servings | Chapati, rice, rice flakes, nachni, semolina |
| Pulses | 3-4 servings | Lentil, Bengal gram, kidney beans |
| Vegetables | 3-4 servings | Green leafy vegetables like Spinach, Radish leaves, shepu etc and other vegetables like cauliflower, beetroot, cucumber etc |
| Fruits | 2-3 servings | Oranges, watermelon, strawberries, apples, pear etc |
| Milk and milk products | 3-4 servings | Milk, curd, paneer, cheese etc |
| Non veg foods | 1-2 servings | Egg, chicken, fish |
| Fats and oils | 30g | Oil, ghee, butter etc. |
- Ballard, O., & Morrow, A. L. (2013). Human Milk Composition. Pediatric Clinics of North America, 60(1), 49-74. doi:10.1016/j.pcl.2012.10.002
- WHO | The World Health Organization's infant feeding recommendation. (2001). Retrieved from http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/
- FAO | Human Energy Requirements. Retrieved from http://www.fao.org/3/a-y5686e.pdf
- ICMR | Nutrient Requirements and Recommended Dietary Allowances (2010) Retrieved from http://www.icmr.nic.in/final/RDA-2010.pdf
- James ML & Mark D. (2010) Effects of Dietary Fiber and Its Components on Metabolic Health. Nutrients, 2(12): 1266–1289
- Jan R & Karen W. Breastfeeding and Human Lactation. 507-508
- NIN| Dietary Guidelines for Indians (2011). Retrieved from http://ninindia.org/DietaryGuidelinesforNINwebsite.pdf
- M Zimmermann M.D. (2011) Handbook of Nutrition- Micronutrients in the Prevention and Therapy of Diseases. 134-138
- B. Srilakshmi. (2009) Dietetics. Nutritional and Food Requirements for Lactating Women. 103-9
- Oxford Journals | Nutrition in Pregnancy and Growth of the Fetus. Retrieved from http://www.oxfordjournals.org/our_journals/tropej/online/mcnts_chap4.pdf
- Food and Nutrition Guidelines for Healthy Pregnant and Breastfeeding Women: A background paper. Retrieved from http://www.health.govt.nz/publication/food-and-nutrition-guidelines-healthy-pregnant-and-breastfeeding-women-background-paper
- Nicotine in Breast Milk. (1934). Journal of School Health, 4(4), 15-16. doi:10.1111/j.1746-1561.1934.tb09597.x
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- Manella J. Alcohol' s Effect on Lactation. Retrieved from http://pubs.niaaa.nih.gov/publications/arh25-3/230-234.htm .
- Eat for Health Australian Dietary Guidelines. (2014). Retrieved from https://www.eatforhealth.gov.au/sites/default/files/files/the_guidelines/n55a_australian_dietary_guidelines_summary_book.pdf
This article is contributed by Nurture Health Solutions
Nutrients that we obtain through food have vital effects on physical growth and development, maintenance of normal body function, physical activity and health. Nutritious food is, thus needed to sustain life and activity. Our diet must provide all essential nutrients in the required amounts. Requirements of essential nutrients vary with age, gender, physiological status and physical activity. Dietary intakes lower or higher than the body requirements can lead to undernutrition (deficiency diseases) or over nutrition (diseases of affluence) respectively. Eating too little food during certain significant periods of life such as infancy, childhood, adolescence, pregnancy and lactation and eating too much at any age can lead to harmful consequences. An adequate diet, providing all nutrients, is needed throughout our lives. The nutrients must be obtained through a judicious choice and combination of a variety of foodstuffs from different food groups. ?¹?
Carbohydrates, fats and proteins are macronutrients, which are needed in large amounts. Vitamins and minerals constitute the micronutrients and are required in small amounts. These nutrients are necessary for physiological and biochemical processes by which the human body acquires, assimilates and utilizes food to maintain health and activity.?¹?
Carbohydrates:
- Carbohydrates are either simple or complex, and are major sources of energy in all human diets. They provide energy of 4 Kcal/g.
- The simple carbohydrates, glucose and fructose, are found in fruits, vegetables and honey, sucrose in sugar and lactose in milk, while the complex polysaccharides are starches in cereals, millets, pulses and root vegetables and glycogen in animal foods.
- The other complex carbohydrates which are resistant to digestion in the human digestive tract are cellulose in vegetables and whole grains, and gums and pectins in vegetables, fruits and cereals, which constitute the dietary fibre component.
- In India, 70-80% of total dietary calories are derived from carbohydrates present in plant foods such as cereals, millets and pulses.?¹? But only 50-60% of the total calories should be derived from carbohydrate. ?²?
- Dietary fibre delays and retards absorption of carbohydrates and fats and increases the satiety value. Dietary fibre is important for proper bowel function, to reduce chronic constipation, diverticular disease, haemorrhoids coronary heart diseases, diabetes and obesity. Diets rich in complex carbohydrates are healthier than low-fibre diets based on refined and processed foods.
- Dietary fibre is characterized as soluble and insoluble.
- Soluble fibre is derived from a variety of sources and widely known ones are modified maltodextrins (reduces blood glucose, promotes growth of healthy bacteria), inulin (from wheat, onions, banana and chicory or synthesized) a probiotic and laxative in nature or oligofructose (fructo oligisaccharides, shown to be associated with inulin or is formed as a by-product of bacterial or fungal action on inulin. ?²?
- Insoluble fibre is composed of structural components of plant cells. Their sources are cereals, seeds, beans, many fruits and vegetables, bran and whole grain. ?²?
- These fibrous compounds may help to promote weight loss, reduce risk of colon cancer and heart disease. ?²?
Proteins :
- Proteins are primary structural and functional components of every living cell. Almost half the protein in our body is in the form of muscle and the rest of it is in bone, cartilage and skin. ?¹?
- Proteins perform a wide range of functions and also provide energy (4 Kcal/g).
- In India less than 10% of calories come from proteins where the recommendation is 10-15% of total calories. ?¹?
- Proteins are complex molecules composed of different amino acids. Certain amino acids which are termed “essential”. Amino acids for which bodily synthesis is inadequate to meet metabolic needs and that must be supplied in the diet. List of essential amino acids are threonine, tryptophan, tyrosine, histidine, lysine, leucine, isoleucine, cysteine, methionine, valine and phenylalanine. ?²? They have to be obtained from proteins in the diet since they are not synthesized in the human body. List of non-essential amino acids are alanine, aspartic acid, asparagine, glutamic acid and serine. These amino acids can be synthesized in the body to build proteins.
- Protein requirements vary with age, physiological status and stress. More proteins are required by growing infants and children, pregnant women and individuals during infections and illness or stress. ?¹?
- Animal foods like milk, meat, fish and eggs and plant foods such as pulses and legumes are rich sources of proteins. Animal proteins are high biological value proteins as they provide all the essential amino acids in right proportions. ?¹?
- Cereal proteins are generally deficient in lysine and pulses or legume proteins contain low amounts of methionine. However, a combination of cereals, millets and pulses provides most of the amino acids, which complement each other to provide better quality proteins.?²?
Fats :
- Oils and fats such as butter, ghee and vanaspathi constitute dietary visible fats.
- Fats are a concentrated source of energy providing 9 Kcal/g, and are made up of fatty acids in different proportions. Dietary fats are derived from two sources viz. the invisible fat present in plant and animal foods; and the visible or added fats and oils (cooking oil).
- Fats serve as a vehicle for fat-soluble vitamins like vitamins A, D, E and K and carotenes and promote their absorption.
- They are also sources of essential polyunsaturated fatty acids. It is necessary to have adequate and good quality fat in the diet with sufficient polyunsaturated fatty acids in proper proportions for meeting the requirements of essential fatty acids.
- The type and quantity of fat in the daily diet influence the level of cholesterol and triglycerides in the blood. ?¹?
- 20-30% of total calories should be derived from both visible and invisible fat. ?¹?
- 0.5 L oil per month is recommended for a disease free adult.
- All fats in foods provide mixtures of three types of fatty acids, which are the “building blocks” of fats. Fatty acids are the primary constituents of all dietary fats. Based on their chemical nature, the fatty acids are broadly grouped as saturated (SFA), monounsaturated (MUFA) and polyunsaturated (PUFA). There are several fatty acids in each group. Adults need to be cautioned to restrict intake of saturated fat (butter, ghee and hydrogenated fats) and cholesterol (red meat, eggs, organ meat). Saturated fatty acids are known to increase serum total and LDL-cholesterol levels, reduce insulin sensitivity and enhance thrombogenicity and increase CVD risk. Therefore, SFA intake should not exceed 8-10% of total energy ?²?
- Oils from sources such as palm, groundnut, cottonseed, sesame and olive are rich in monounsaturated fatty acids as compared to other oils. Linoleic (n-6) and -linolenic (n-3) acids are the simple PUFA, which are present only in plant foods ?²?
- (can we give examples) For ensuring this appropriate balance of fatty acids in cereal-based diets, it is necessary to increase the a-linolenic (n-3) acid intake and reduce the quantity of linoleic (n-6) acid obtained from the cooking oil. A blend of two or more vegetable oils to be used in daily cooking is advised. Hence, the choice of cooking oil should be as follows (2).
-- Groundnut or Sesame or Rice bran + Mustard.
-- Groundnut or Sesame or Rice bran + Soyabean.
-- Groundnut or Sesame or Rice bran + Canola
Vitamins and Minerals :
- Vitamins are chemical compounds required by the body in small amounts. They must be present in the diet as they cannot be synthesized in the body.
- Vitamins are essential for numerous body processes and for maintenance of the structure of skin, bone, nerves, eye, brain, blood and mucous membrane.
- They are either water soluble or fat-soluble. Vitamins A, D, E and K are fat-soluble, while vitamin C, and the B-complex vitamins are water soluble. Fat-soluble vitamins can be stored in the body while water-soluble vitamins are not and get easily excreted in urine. Vitamins B-complex and C are heat labile vitamins and are easily destroyed by heat, air or during drying, cooking and food processing.
- Minerals are inorganic elements found in body fluids and tissues.
- The important macro minerals are sodium, potassium, calcium, phosphorus, magnesium and sulphur, while zinc, copper, selenium, molybdenum, fluorine, cobalt, chromium and iodine are micro minerals.
- They are required for maintenance and integrity of skin, hair, nails, blood and soft tissues. They also govern nerve cell transmission, acid/base and fluid balance, enzyme and hormone activity as well as the blood- clotting processes. ?¹)
What are food groups? ?¹?
- Cereals, Pulses and Legumes.
- Milk and Milk products, Eggs and Poultry.
- Vegetables and Fruits.
- Oil, Fats, Nuts and Oilseeds.
What is a Balanced Diet? ?¹?
- A balanced diet is one which provides all the nutrients in required amounts and proper proportions. It can easily be achieved through a blend of the four basic food groups.
- The proper quantities of foods needed to meet the nutrient requirements vary with age, gender, physiological status and physical activity.
- A balanced diet for a normal sedentary adult should provide around 50-60% of total calories from carbohydrates, preferably from complex carbohydrates, about 10-15% from proteins and 20-30% from both visible and invisible fat.
- In addition, a balanced diet should provide other non-nutrients such as dietary fibre, antioxidants and phytochemicals which bestow positive health benefits.
- Antioxidants such as vitamins C and E, beta-carotene, riboflavin and selenium protect the human body from free radical damage. Spices like turmeric, ginger, garlic, cumin and cloves are rich in antioxidants.
- Other phytochemicals such as polyphenols, flavones, etc., also afford protection against oxidant damage.
Dietary Recommendations ?¹?
- Choose a variety of foods in amounts appropriate for age, gender, physiological status and physical activity.
- Use a combination of whole grains, grams and greens.
- Prefer fresh, locally available vegetables and fruits in plenty. Wash vegetables and fruits thoroughly before use.
- Encourage incorporation of vegetables/ fruits in all meals in various forms (raw salads, curry, soups, mixed with curd, added to pulse preparations and rice).
- Let different varieties of vegetables and fruits add colour to the plate and vitality to life.
- Include in the diets, foods of animal origin such as milk, eggs and meat, particularly for pregnant and lactating women and growing children.
- Adults should choose low-fat, protein-rich foods such as lean meat, fish, pulses and low-fat milk.
- Develop healthy eating habits and exercise regularly and move as much as one can to avoid sedentary lifestyle.
- Drink plenty of water (2 – 3 litres) per day
- Take just enough fat.
- Substitute part of visible fat and invisible fat from animal foods with whole nuts.
- Moderate the use of animal foods containing high fat, SFA and cholesterol.
- Limit the use of ghee, butter, especially vanaspati as a cooking oil.
- Choose low- fat dairy foods in place of regular whole fat dairy foods.
- Eat foods rich in alpha-linolenic (ALA) acid such as legumes, green leafy vegetables, fenugreek and mustard seeds.
- Eat fish more frequently (at least 100-200g /week), prefer it to meat, and avoid organ meats such as liver, kidney, brain etc.
- Egg has several important nutrients. But limit the consumption to 3 eggs/ week. However, egg white may be consumed in good amounts.
- Minimize consumption of ready- to- eat fast foods, bakery foods and processed foods prepared in hydrogenated fat.
- Use of re-heated fats and oils should be avoided, as it may lead to increase in trans fatty acids
- Limit the oil/fat intake to 3-4 tsp/day, which includes oil, ghee, butter. A blend of two or more vegetable oils is advised to get good proportion of all fatty acids for optimal health benefits.
- A minimum 30-45 minutes’ brisk walk/physical activity of moderate intensity improves overall health.
- Include ‘warm-up ’and ‘cool- down’ periods, before and after the exercise regimen.
- 45 minutes per day of moderate intensity physical activity provides many health benefits.
- National Institute of Nutrition; Dietary Guidelines for Indians – A Manual – 2011.
- National Institute of Nutrition; Nutrient Requirements and Recommended Dietary Allowances for Indians - A Report of the Expert Group of the Indian Council of Medical Research 2009.
This article is contributed by Nurture Health Solutions