ADULTHOOD

General Objective:
To relate the nutritional
requirements of adults to their
physiological status.

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 Specific Objectives
• Describe the physiological changes experienced during
adulthood.
• Describe major health concerns in adulthood in terms
of their prevalence, modifiable and non-modifiable risk
factors and basic principles of dietary management:
• Relate the physiological changes and lifestyle practices
of adults to their risk of developing major health
concerns.
• Relate the importance of nutrition in adulthood to
prevent the development of major health concerns.
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 Maturity = the state of full & complete development & growth
Adulthood
The adult stage of the life cycle refers to the years of maturity

Senescence = the process of growing old

between adolescence & senescence.
It begins with the attainment of sexual maturation & completion of
growth. It is a period of physiologic homeostasis characterized by
gradual changes of aging.
Legal age of adulthood: 18 or 21 in different countries

The Early Years 20 – 30s

The Middle Years 40 – 50s

The Older Years

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60 – 80s
 Musculoskeletal System

Most body systems reach their peak efficiency & optimum

functioning before age 30.
There is completion of skeletal growth, characterized by the
achievement of maximum height & the formation of peak bone
mass.
• Muscle mass increases into the 30s & then declines.
• 5 years after maximum height is attained, an adult reaches
maximum strength, endurance & agility. From this point, there is a
gradual & steady decline.
• Bone mass increases well into the 30s, then both men & women
experience a continuous loss of bone mineral density (BMD).
• Because these changes are gradual, the decline may not be
apparent for more than a decade; however, these changes
accelerate after middle age. 4

Stability is the major physiologic characteristic of adulthood.

 Muscle Mass & Strength

EARLY LIFE ADULT LIFE OLDER LIFE

MUSCLE MASS & STRENGTH

Range between
individuals

Growth &
development phase –
maximize peak Maintain peak Minimizing loss 5

AGE
 Body Composition
With overall growth achieved, an adult pattern of body
composition is established.

Body weight = Fat Mass + Fat-free Mass

• At entry to adulthood, women have a larger fat mass
& lower fat-free mass than men.
(♀ 18-23% body fat, ♂ 15%)

Over time, body composition changes:

• increase in % fat mass, reduction in fat-free mass in
both men & women.
• fat mass is more & fluctuates more in women.
(by age 60: ♀ 32% body fat, ♂ 25%)

• increased body fatness is linked with ↑ risk of type 2

diabetes, hypertension, cardiovascular diseases. 6
 Body Weight

processes involved in the body's normal functioning.

The term "metabolic" refers to the biochemical
When muscle mass declines, resting energy expenditure
(REE) also decreases.
• This translates into reduced calorie requirements.
• Failure to adjust dietary intake & physical activity levels
lead to excess gains of body weight & fat.

• Extra pounds tend to settle around the

waist → ↑ risks for hypertension, diabetes
& coronary heart disease.
• To maintain the weight of early adulthood
is an appropriate lifetime goal.
• To identify increased metabolic risk
associated with accumulation of
abdominal fat, measurement of waist 7
circumferences is recommended.
 BMI
WHO Cut-off Risk of co- Asian Cut-off
Category CVD risk
points morbidities points
Underweight < 18.5 Low < 18.5 Low
Normal range 18.5 – 24.9 Average 18.5 – 22.9
Overweight ≥ 25.0
• Pre-obese 25.0 – 29.9 Increased 23.0 – 27.4 Moderate
• Obese class I 30.0 – 34.9 Moderate 27.5 – 32.4 High
• Obese class II 35.0 – 39.9 Severe 32.5 – 37.4 Very High
• Obese class III ≥ 40.0 Very severe ≥ 37.5

If BMI < 18.5kg/m2 , increased risk of nutritional deficiencies and osteoporosis.

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 Weight Status

Weight status (Based on National Health Survey 2010

WHO classification) Males (%) Females (%) Total (%)
Underweight 4.5 8.2 6.4
(BMI <18.5)
Normal 48.9 58.0 53.5
(BMI 18.5-24.9)
Preobese 34.5 24.3 29.3
(BMI 25-29.9)
Obese 12.1 9.5 10.8
(BMI > 30)

Prevalence of obesity %
Chinese 7.9 9
Malay 24.0
Next National Health Survey – 2016/2017
Indians 16.9 results be out in 2019
 Health risks of overweight / obesity

HIGH
TRIGLYCERIDE
HIGH LOW HDL
BLOOD
PRESSURE

DIABETES OVERWEIGHT CVD

ELEVATED OBESITY HIGH LDL
BLOOD
GLUCOSE

JOINT INSULIN INFLAMMATORY STROKE

PROBLEMS RESISTANCE MARKERS

SOME
CANCERS
 Principal Causes Of Death
(% of total deaths)
1. Cancer (29.4%)
2. Pneumonia (19.0%)
3. Ischemic heart diseases - IHD (16.0%)
4. Cerebrovascular Diseases, Including Stroke (8.4%)
5. External Causes of Morbidity and Mortality (4.7%)
6. Hypertensive Diseases(3.6%)
7. Urinary Tract Infection (2.6%)
8. Nephritis, Nephrotic Syndrome & Nephrosis (2.0%)
9. Other Heart Diseases (1.9%)
10. Chronic Obstructive Lung Disease (1.8%)
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 Psychosocial / Lifestyles

Psychologic stress, social pressures & sedentary lifestyles can contribute to poor
dietary & activity patterns with negative health implications.
• Busy schedules
• on the go all the time: dependence on food eaten outside, convenience foods,
processed foods (high sodium, fats/unhealthy fats, low nutrient density, low fiber)
• skipping meals
• Entertainment/affluence  rich foods, alcohol
• Difficulty finding time for exercise
• Smoking: causes cell
damage, increases
risk for diseases, NNS2004 (%) NNS2010 (%)

drains the body of Skipping breakfast 6.9 14.1

essential nutrients Eating out at least 4 times/week 47.8 60.1
e.g. vit C to NHS2004 (%) NHS2010 (%)
counteract the Daily smoking 12.3 14.3
damage to cells. Regular alcohol consumption 3.3 2.6 12
Leisure time regular exercise 16.9 19.0
 Nutrition & The Adult Years
During the early years (20 – 30s) establishment of positive
health behaviors is desirable.
• These years are the childbearing & childrearing years
with health implications for both men & women.
The middle years (40 – 50s) are years of career & family
demands.
• Chronic diet-related diseases may present during these
years. Positive dietary & exercise behaviors may provide
protection.
• Nutrient needs of women change as menopause occurs.
The older years (60 – 80s) are most reflective of lifestyle
behaviors practiced over many years. (more details in topic on 13
elderly)
 Importance of Nutrition
Good nutrition is important throughout the life
cycle.

Nutrition in the adult years emphasizes the

importance of establishing healthy diets &
lifestyles in maintaining wellness & preventing
future development of diet-related diseases.

Focus in adulthood: nutrition for promoting lifelong health

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 Dietary Intakes

Dietary excess = intake above or beyond Dietary insufficiency = intake below

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recommended levels (>100% of respective recommended levels (<70% of respective
RDA) RDA)
Health Concerns of Adults
Overweight/obesity
Dyslipidemias
• High blood cholesterol
• Low HDL
• High LDL
Cardiovascular disease CVD
• hypertension
• coronary heart disease CHD
Type 2 diabetes
Cancers 16
Menopause
 Prevalence of Health Conditions

Health NHS 2004 NHS 2010 National Health Survey 2010

Condition % % Males Females Malay Indian Chinese
(%) (%) (%) (%) (%)
Diabetes 8.2 11.3 12.3 10.4 16.6 17.2 9.7

Hypertension 24.9 23.5 26.4 20.7 28.0 19.3 23.4

High blood 18.7 17.4 18.3 16.5 22.6 12.6 17.1

cholesterol
Obesity 6.9 10.8 12.1 9.5 24.0 16.9 7.9

Abdominal 11.9 16.9 5.6 28.0 18.9 26.1 15.5 17

fatness
 HYPERTENSION
Hypertension is defined as blood pressure exceeding
140/90 mmHg

SYSTOLIC DIASTOLIC
A silent killer (no symptoms) → many people are undiagnosed or have
poorly controlled hypertension.
Most causes of hypertension are unknown, it is probable that causes
are multiple & inter-related.
These factors increase one’s risk of hypertension:
Non-modifiable factors Modifiable factors Chronic hypertension is a
Increasing age, esp > 55 yr Overweight/obesity major risk factor for
Race e.g. among blacks Diabetes coronary heart disease,
Heredity (family history) High salt intake stroke & kidney failure. 18
Physical inactivity
Smoking
 Classification of BP levels for
adults
Blood Pressure Level (mmHg)
Category Systolic BP Diastolic BP
(mmHg) (mmHg)

Normal BP <130 <85

High - Normal BP 130 – 139 85 -89
Grade 1 Hypertension 140-159 90-99
Grade 2 Hypertension 160-179 100-109
Grade 3 Hypertension ≥180 ≥90
MOH CPG 2017

For adults 18 and older who are not on medication for HPT; are not having a short-
term serious illness; and do not have other conditions e.g. diabetes and kidney disease.
As BP is characterised by large spontaneous variations, the diagnosis of
hypertension should be based on multiple BP measurements taken on
several separate occasions 19
 Hypertension - Prevention &
Treatment
The emphasis on lifestyle modifications has given diet a
prominent role for the prevention & management of
hypertension.
Dietary Approaches to Stop Hypertension (DASH) Eating
Plan:
• Lower sodium intake to < 2400 mg/day (biggest
benefits at sodium level <1500 mg/day)
• Increase potassium, calcium & magnesium from
fruits, vegetables & low fat dairy foods
• Lower fat, saturated fat & cholesterol intakes
• Moderate alcohol intake
• Weight control if overweight 20
 Coronary Heart Disease
Atherosclerosis, the most common cause of CHD, is characterized by
plagues along the inner walls of arteries which occlude the affected
artery & restrict blood flow to the heart  heart attack.
In the same way, occlusion of cerebral artery  stroke.
These factors increase one’s risk of CHD:

Non-modifiable factors Modifiable factors

Increasing age, esp > 45 yr Overweight/obesity esp abdominal obesity
CHD leads
Gender - males Health conditions - diabetes, hypertension,
to angina
dyslipidemia (chest
Heredity (family history) Physical inactivity pain),
Postmenopausal status Smoking heart
Unhealthy diets: attack &
• high in fat, saturated fat, trans fat, deaths. 21
cholesterol
• low in dietary fiber, vits B6, B12 & folate
which increases homocysteine levels
 Standards for CHD Risk Assessment

Clinical measures Desirable Borderline risk High risk

Total cholesterol mmol/L < 5.3 5.3 - 6.3 ≥ 6.3

mg/dL < 200 200 - 239 ≥ 240
LDL cholesterol mmol/L < 2.6 3.4 - 4.2 4.2 - 5.0
mg/dL (< 100) (130 - 159) (160 - 189)
HDL cholesterol mmol/L ≥ 1.6 1.6 - 1.1 < 1.1
mg/dL (≥ 60) (59 - 40 for men, (< 40 for men,
59 - 50 for women) < 50 for women
Triglycerides mmol/L < 1.7 1.7 - 2.2 2.2 - 5.5
mg/dL (< 150) (150 – 199) (200 - 499)
BMI kg/m2 18.5 - 24.9 25 - 29.9 ≥ 30
Blood pressure mmHg < 120 / < 80 120 – 139 / 80 - 89 ≥ 140 / ≥ 90

MOH CPG 2016 22

 CHD - Prevention & Treatment

AHA/ACC 2013 Guidelines on Lifestyle Management to Reduce

Cardiovascular Risk
• A diet rich in vegetables, fruits & wholegrains, incorporating
low fat dairy products. Recommended protein sources 
fish, legumes & poultry; recommended sources of fats 
vegetable oils & nuts. Limit sugar-sweetened beverages &
red meat.
• Three plans that exemplify this pattern: DASH, USDA Food
Pattern, AHA Diet.
• Reduce saturated fat to 5-6% calories, reduce trans fat.
• Restrict sodium to < 2400 mg/day, & if possible < 1500
mg/day.
• Physical activity: 3-4 sessions of moderate-to-vigorous 23
intensity aerobic activity/week, average 40 minutes/session.
 DIABETES MELLITUS
A metabolic disorder in which blood glucose levels are
abnormally high.
• Type 1 diabetes – body produces no insulin, about 10% of
cases, mostly < age 30.
• Type 2 diabetes - body develops resistance to the effects of
insulin, about 90% of cases, in people > 30.

Obese / overweight is the main risk factor for developing type 2

diabetes
• Gestational Diabetes : Occurs in about 2 to 5 percent of all
pregnancies. Women who were not diagnosed to have diabetes
previously show high blood glucose levels during pregnancy.

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 Diabetes Mellitus
Non-modifiable factors Modifiable factors
Increasing age, esp > 45 yr Overweight/obesity esp abdominal obesity
Race – esp African/Native/Hispanic Health conditions - hypertension, dyslipidemia
Americans, Asians & Pacific Islanders
Heredity (family history) Physical inactivity
gestational diabetes or delivering a
baby > 9 lb (4 kg)
Diabetes is a major risk factor for CHD, stroke & kidney failure.
It also increases the risk of poor eyesight (& possibly blindness), nerve damage
& damage to the circulation (leading to amputation).

There is no cure for diabetes.

Maintaining an ideal body weight & an active lifestyle may prevent the onset of
type 2 diabetes. 25
Treatment involves medicines – oral tablets or insulin injections, diet & exercise
to control blood sugar & prevent complications.
 Screening for Diabetes Mellitus

Test (mmol/L) Normal Diabetic

Random blood glucose < 7.8 ≥ 11.1

(check at any time of the day)
Fasting blood glucose ≤ 6.0 ≥ 7.0
(tested in the morning after 8
hours of overnight fast)

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 Diabetes - Prevention & Treatment

2013 ADA Nutritional Recommendations

There is no standard meal plan or eating pattern
that works universally for all people with diabetes
 individualize. Emphasis is on a variety of
minimally processed nutrient-dense foods in
appropriate portion sizes as part of a healthful
eating pattern.
• Monitor CHO intake to achieve good glycemic control. CHO from
vegetables, fruits, whole grains, legumes & low fat dairy products.
Avoid refined CHO & added sugar, especially sugar-sweetened
beverages. Half the grains should be whole grains. Eat fatty fish. Limit
salt intake. Keep saturated fat low.
• Modest weight loss  most of the benefit of weight loss is achieved
by losing 5-10% of body weight, prevent weight gain. 27
• Moderate alcohol consumption for people who drink, but watch for
hypoglycemia if on medications.
 The Metabolic Syndrome
The metabolic syndrome is characterized by a group of metabolic
risk factors in one person.

They include:
• Abdominal obesity
• Atherogenic dyslipidemia (high
triglycerides, low HDL and high LDL)
• Elevated blood pressure
• Insulin resistance or glucose intolerance
• Prothrombotic state (e.g. high fibrinogen
or plasminogen activator inhibitor–1)
• Inflammatory markers (e.g. elevated C-reactive
protein)
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 The Metabolic Syndrome
People with the metabolic syndrome are at
increased risk of:
• CHD
• diseases related to plaque buildups in artery
walls (e.g. stroke & peripheral vascular disease)
• type 2 diabetes
The dominant underlying risk factors for this
syndrome appear to be
This syndrome is also
• abdominal obesity and called the insulin
• insulin resistance resistance syndrome
Other conditions associated with the syndrome include
physical inactivity, aging, hormonal imbalance and genetic
predisposition 29
 Metabolic Consequence of
Obesity
The metabolic consequences of obesity are highly
dependent on fat distribution.
Increased abdominal fat is associated with insulin
resistance.
• Abdominal adipocytes release free fatty acids more
readily under the influence of catecholamines, and
these fatty acids in the portal circulation may result to
insulin resistance.
• In fact, abdominal obesity is associated with
hyperinsulinemia, hypertriglyceridemia, glucose
intolerance, hypertension and common forms of
cancer.

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 Diagnosis of Metabolic Syndrome

3 or more of the following 5:

Measure Diagnostic cut-off point
Abdominal Obesity Waist circumference ≥ 90 cm in ♂ and ≥
80 cm in ♀ (WHO:102 cm in ♂ and ≥ 88 cm in ♀)
Hyperglycemia Fasting glucose levels > 100 mg/dL (5.6
mmol/L) or active treatment for
hyperglycemia
Hypertriglyceridemia Triglycerides ≥ 150 mg/dL (1.7 mmol/L)
Reduced HDL- HDL cholesterol < 40 mg/dL or 1.03
cholesterol mmol/L for ♂, < 50 mg/dL or 1.29 mmol/L
for ♀
Hypertension Blood pressure > 130/85 mmHg or active
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treatment for hypertension
 CANCER

Malignant tumors that multiply out of control, spread to

other parts of the body, threaten health & require
treatment.
• Some cancers are associated with exposure to
sunlight/ionizing radiation, certain chemicals, smoking &
lifestyle factors (obesity, high consumption of alcohol, red
meats).
• Some are associated with chronic infections, such as liver
cancer (hepatitis B virus), cervical cancer (human
papillomavirus) & stomach cancer (Helicobacter pylori).
Cancer is a disease associated with aging → as populations
age, the burden of cancer is expected to increase.
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 Cancer - Prevention
ACS Guidelines on Nutrition &
Men Women Physical Activity for Cancer
Lung Breast Prevention 2012
Colo-rectum Lung • Achieve & maintain a healthy
weight throughout life.
Liver Colo-rectum
Stomach Liver
• Adopt a physically active
lifestyle.
Pancreas Stomach
• Consume a healthy diet, with an
Prostate Pancreas emphasis on plant foods.
• Limit consumption of processed
Nasopharynx Ovary meat & red meat.
Lymphomas Cervix uteri • Eat at least 2.5 cups of
vegetables & fruits each day.
Kidney & other urinary Lymphomas
• Choose whole grains instead of
Leukemias Leukemias refined grain products.
• If you drink alcoholic beverages, 33
limit consumption.
 MENOPAUSE
• Towards the end of a woman’s reproductive period,
estrogen & progesterone levels fluctuate wildly &
progressively decline.
• A variety of symptoms: hot flashes, vaginal
dryness, fatigue, anxiety, sleep disturbances,
memory & concentration problems.
• Menstrual cycles become irregular & eventually
menstruation ends.
• Postmenopause is characterized by increased
vulnerability to heart disease, osteoporosis & breast
cancer.
• Hormone Replacement Therapy (HRT) relieves many of the
symptoms of perimenopause & may protect against
osteoporosis & CHD.
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 OSTEOPOROSIS (’porous bone’)

Beginning in the 3rd decade, continuous loss of bone mineral density

(BMD).
• The rate of bone loss is similar in women & men except for a 5 – 10
year period of very rapid postmenopausal bone loss in women. After
this period, the rate of loss reverts to the lower value observed in
premenopausal women & in men.
• This increase in bone loss rate, coupled with the typically smaller
peak bone mass in women, explains the greater frequency of bone
fractures among older women than among older men.
Two types of bone are affected by
osteoporosis:
• Cortical bone - the compact outer
layer of the bone shaft
• Trabecular bone - a meshlike inner
structure found in high percentages in
the hip, spine & wrist. It is more 35
vulnerable because it has a higher
turnover rate.
 Changes in BMD
Anabolism > Anabolism = Catabolism >
Catabolism Catabolism Anabolism

Males
Females (with
estrogen replacement)
BONE MASS

Females (without
Consolid- estrogen replacement)
Growth ation Rapid bone loss Gradual bone loss
phase phase 36

20 40 60 80 100
AGE
 Consequences of Normal bone Porous bone

Osteoporosis
People with osteoporosis will suffer from
• pain in the bones or muscles, especially
in areas around the lower back
• spinal compression fractures resulting
in loss of height with a stooped back
(called dowager's hump)
• fractures in the hip & spine  almost
always result in serious consequences

Over the last 30 years in Singapore, cases of hip fractures have increased 5 37
times in women aged >50 yr & 1.5 times in men of the same age group.

http://www.orthogate.org Mar14
 Osteoporosis – Prevention
& Treatment
National Osteoporosis Foundation 2010
• Lifelong adequate calcium intake to acquire peak bone mass &
maintain bone health
• Adequate vit D for calcium absorption & bone health
• Regular weight bearing & muscle strengthening exercises
• Avoid smoking & excessive alcohol
• Fall prevention
• Medications If bone density is low but not low enough to
be considered osteoporosis = osteopenia
(‘deficient bone’) → at high risk.

Non-modifiable factors Modifiable factors

Increasing age, after mid-30s Low levels of estrogen
Race – non-Hispanic white or Asian Lifestyle – smoking, alcohol, physical inactivity
Heredity (family history) Eating disorders – anorexia nervosa & bulimia 38
Postmenopausal status Diet – low calcium & vit D intakes/absorption
Prior fracture
 Nutrition Assessment for Adults

• Nutrition assessment for adults focuses on

identification of individuals at risk of malnutrition.
• Assessing risk for nutrition-related chronic
diseases are essential for early identification &
intervention & for monitoring the effectiveness of
nutrition care.
• Of particular importance is monitoring the
parameters related to major causes of death &
disability – obesity, diabetes, hypertension &
CHD.
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