INTRODUCTION TO

NUTRITION SCIENCE
Introduction to Nutrition Science
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TABLE OF CONTENTS
Licensing

1: Basic Concepts in Nutrition

1.1: Introduction
1.2: What Are Nutrients?
1.3: Food Quality
1.4: Units of Measure
1.5: The Broad Role of Nutritional Science
1.6: Research and the Scientific Method

2: Achieving a Healthy Diet

2.1: Chapter Introduction
2.2: A Healthy Philosophy toward Food
2.3: What Is Nutritional Balance and Moderation?
2.4: National Goals for Nutrition and Health- Healthy People 2020
2.5: Recommendations for Optimal Health
2.6: Understanding Dietary Reference Intakes (DRI)
2.7: Understanding the Bigger Picture of Dietary Guidelines
2.8: Discovering Nutrition Facts
2.9: Building Healthy Eating Patterns
2.10: When Enough is Enough
2.11: Nutrition and the Media

3: The Human Body

3.1: Introduction to the Human Body
3.2: The Basic Structural and Functional Unit of Life- The Cell
3.3: Basic Biology, Anatomy, and Physiology
3.4: The Digestive System
3.4.1: Digestion and Absorption
3.5: The Cardiovascular System
3.6: Central Nervous System
3.7: The Respiratory System
3.8: The Endocrine System
3.9: The Urinary System
3.10: The Muscular System
3.11: The Skeletal System
3.12: The Immune System
3.13: Indicators of Health- Body Mass Index, Body Fat Content, and Fat Distribution

4: Carbohydrates
4.1: Introduction to Carbohydrates
4.2: Digestion and Absorption of Carbohydrates
4.3: The Functions of Carbohydrates in the Body
4.4: Health Consequences and Benefits of High-Carbohydrate Diets

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 4.5: Looking Closely at Diabetes
4.6: Carbohydrates and Personal Diet Choices
4.7: The Food Industry- Functional Attributes of Carbohydrates and the Use of Sugar Substitutes

5: Lipids
5.1: Introduction to Lipids
5.2: The Functions of Lipids in the Body
5.3: The Role of Lipids in Food
5.4: How Lipids Work
5.5: Nonessential and Essential Fatty Acids
5.6: Digestion and Absorption of Lipids
5.7: Tools for Change
5.8: Lipids and the Food Industry
5.9: Lipids and Disease
5.10: Understanding Blood Cholesterol and Heart Attack Risk
5.11: A Personal Choice about Lipids
5.E: Lipids (Exercises)

6: Protein
6.1: Introduction to Protein
6.2: Defining Protein
6.3: The Role of Proteins in Foods- Cooking and Denaturation
6.4: Protein Digestion and Absorption
6.5: Protein’s Functions in the Body
6.6: Diseases Involving Proteins
6.7: Proteins in a Nutshell
6.8: Proteins, Diet, and Personal Choices

7: Vitamins
7.1: Introduction to Vitamins
7.2: Fat-Soluble Vitamins
7.3: Water-Soluble Vitamins
7.4: Antioxidants
7.5: The Body’s Offense
7.6: Phytochemicals

8: Water and Electrolytes

8.1: Introduction to Water and Electrolytes
8.2: Overview of Fluid and Electrolyte Balance
8.3: Water’s Importance to Vitality
8.4: Regulation of Water Balance
8.5: Electrolytes Important for Fluid Balance
8.6: Sodium
8.7: Chloride
8.8: Potassium
8.9: Consequences of Deficiency or Excess
8.10: Water Concerns
8.11: Popular Beverage Choices

2 [Link]
9: Major Minerals
9.1: Introduction to Major Minerals
9.2: Calcium
9.2.1: Bone Structure and Function
9.2.2: Bone Mineral Density is an Indicator of Bone Health
9.2.3: Micronutrients Essential for Bone Health- Calcium and Vitamin D
9.2.4: Osteoporosis
[Link]: Risk Factors for Osteoporosis
[Link]: Osteoporosis Prevention and Treatment
9.3: Phosphorus
9.4: Magnesium
9.5: Summary of Major Minerals

10: Trace Minerals

10.1: Introduction to Trace Minerals
10.2: Iron
10.3: Zinc
10.4: Selenium
10.5: Iodine
10.6: Chromium
10.7: Fluoride
10.8: Summary of Trace Minerals

11: Food Safety

11.1: Introduction to Food Safety
11.2: The Major Types of Foodborne Illness
11.3: The Causes of Food Contamination
11.4: Protecting the Public Health
11.5: The Food System
11.6: Food Preservation
11.7: Food Processing
11.8: The Effect of New Technologies
11.9: Efforts on the Consumer Level- What You Can Do

12: Nutritional Issues

12.1: Introduction to Nutritional Issues
12.2: Comparing Diets
12.3: Calories In Versus Calories Out
12.4: Nutrition, Health and Disease
12.5: Threats to Health
12.6: Undernutrition, Overnutrition, and Malnutrition
12.7: Food Insecurity
12.8: Careers in Nutrition

13: Performance Nutrition

13.1: Introduction to Performance Nutrition
13.2: The Essential Elements of Physical Fitness

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 13.3: The Benefits of Physical Activity
13.4: Fuel Sources
13.5: Sports Nutrition
13.6: Water and Electrolyte Needs
13.7: Food Supplements and Food Replacements

14: Lifespan Nutrition From Pregnancy to the Toddler Years

14.1: Introduction to Lifespan Nutrition From Pregnancy to the Toddler Years
14.2: Pregnancy
14.3: Infancy
14.4: Toddler Years

15: Lifespan Nutrition in Adulthood

15.1: Introduction to Lifespan Nutrition in Adulthood
15.2: Young Adulthood
15.3: Middle Age
15.4: Older Adulthood- The Golden Years

16: Food Politics and Perspectives

16.1: Prelude to Food Politics and Perspectives
16.2: Historical Perspectives on Food
16.3: The Food Industry
16.4: The Politics of Food
16.5: Food Cost and Inflation
16.6: The Issue of Food Security
16.7: Nutrition and Your Health
16.8: Diets around the World
16.E: Food Politics and Perspectives (Exercise)

Index

Glossary

Detailed Licensing

4 [Link]
Licensing
A detailed breakdown of this resource's licensing can be found in Back Matter/Detailed Licensing.

1 [Link]
 CHAPTER OVERVIEW

1: Basic Concepts in Nutrition

1.1: Introduction
1.2: What Are Nutrients?
1.3: Food Quality
1.4: Units of Measure
1.5: The Broad Role of Nutritional Science
1.6: Research and the Scientific Method

This page titled 1: Basic Concepts in Nutrition is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer
Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts
platform.

1
1.1: Introduction
ʻO ke kahua ma mua, ma hope ke kūkulu
The foundation comes first, then the building

Image by Jim Hollyer / CC BY 4.0

 Learning Objectives
By the end of this chapter, you will be able to:
Describe basic concepts in nutrition
Describe factors that affect your nutritional needs
Describe the importance of research and scientific methods to understanding nutrition

What are Nutrients?

The foods we eat contain nutrients. Nutrients are substances required by the body to perform its basic functions. Nutrients must be
obtained from our diet, since the human body does not synthesize or produce them. Nutrients have one or more of three basic
functions: they provide energy, contribute to body structure, and/or regulate chemical processes in the body. These basic functions
allow us to detect and respond to environmental surroundings, move, excrete wastes, respire (breathe), grow, and reproduce. There
are six classes of nutrients required for the body to function and maintain overall health. These are carbohydrates, lipids, proteins,
water, vitamins, and minerals. Foods also contain non-nutrients that may be harmful (such as natural toxins common in plant foods
and additives like some dyes and preservatives) or beneficial (such as antioxidants).

Macronutrients
Nutrients that are needed in large amounts are called macronutrients. There are three classes of macronutrients: carbohydrates,
lipids, and proteins. These can be metabolically processed into cellular energy. The energy from macronutrients comes from their
chemical bonds. This chemical energy is converted into cellular energy that is then utilized to perform work, allowing our bodies to
conduct their basic functions. A unit of measurement of food energy is the calorie. On nutrition food labels the amount given for
“calories” is actually equivalent to each calorie multiplied by one thousand. A kilocalorie (one thousand calories, denoted with a
small “c”) is synonymous with the “Calorie” (with a capital “C”) on nutrition food labels. Water is also a macronutrient in the sense
that you require a large amount of it, but unlike the other macronutrients, it does not yield calories.

Carbohydrates
Carbohydrates are molecules composed of carbon, hydrogen, and oxygen. The major food sources of carbohydrates are grains,
milk, fruits, and starchy vegetables, like potatoes. Non-starchy vegetables also contain carbohydrates, but in lesser quantities.

1.1.1 [Link]
Carbohydrates are broadly classified into two forms based on their chemical structure: simple carbohydrates, often called simple
sugars; and complex carbohydrates.
Simple carbohydrates consist of one or two basic units. Examples of simple sugars include sucrose, the type of sugar you would
have in a bowl on the breakfast table, and glucose, the type of sugar that circulates in your blood.
Complex carbohydrates are long chains of simple sugars that can be unbranched or branched. During digestion, the body breaks
down digestible complex carbohydrates to simple sugars, mostly glucose. Glucose is then transported to all our cells where it is
stored, used to make energy, or used to build macromolecules. Fiber is also a complex carbohydrate, but it cannot be broken down
by digestive enzymes in the human intestine. As a result, it passes through the digestive tract undigested unless the bacteria that
inhabit the colon or large intestine break it down.
One gram of digestible carbohydrates yields four kilocalories of energy for the cells in the body to perform work. In addition to
providing energy and serving as building blocks for bigger macromolecules, carbohydrates are essential for proper functioning of
the nervous system, heart, and kidneys. As mentioned, glucose can be stored in the body for future use. In humans, the storage
molecule of carbohydrates is called glycogen, and in plants, it is known as starch. Glycogen and starch are complex carbohydrates.

Lipids
Lipids are also a family of molecules composed of carbon, hydrogen, and oxygen, but unlike carbohydrates, they are insoluble in
water. Lipids are found predominantly in butter, oils, meats, dairy products, nuts, and seeds, and in many processed foods. The
three main types of lipids are triglycerides (triacylglycerols), phospholipids, and sterols. The main job of lipids is to provide or
store energy. Lipids provide more energy per gram than carbohydrates (nine kilocalories per gram of lipids versus four kilocalories
per gram of carbohydrates). In addition to energy storage, lipids serve as a major component of cell membranes, surround and
protect organs (in fat-storing tissues), provide insulation to aid in temperature regulation, and regulate many other functions in the
body.

Proteins
Proteins are macromolecules composed of chains of subunits called amino acids. Amino acids are simple subunits composed of
carbon, oxygen, hydrogen, and nitrogen. Food sources of proteins include meats, dairy products, seafood, and a variety of different
plant-based foods, most notably soy. The word protein comes from a Greek word meaning “of primary importance,” which is an
apt description of these macronutrients; they are also known colloquially as the “workhorses” of life. Proteins provide four
kilocalories of energy per gram; however providing energy is not protein’s most important function. Proteins provide structure to
bones, muscles and skin, and play a role in conducting most of the chemical reactions that take place in the body. Scientists
estimate that greater than one-hundred thousand different proteins exist within the human body. The genetic codes in DNA are
basically protein recipes that determine the order in which 20 different amino acids are bound together to make thousands of
specific proteins.

Figure 1.1 The Macronutrients: Carbohydrates,

Lipids, Protein, and Water. Figure 1.1 The Macronutrients: Carbohydrates, Lipids, Protein, and Water

1.1.2 [Link]
Water
There is one other nutrient that we must have in large quantities: water. Water does not contain carbon, but is composed of two
hydrogens and one oxygen per molecule of water. More than 60 percent of your total body weight is water. Without it, nothing
could be transported in or out of the body, chemical reactions would not occur, organs would not be cushioned, and body
temperature would fluctuate widely. On average, an adult consumes just over two liters of water per day from food and drink
combined. Since water is so critical for life’s basic processes, the amount of water input and output is supremely important, a topic
we will explore in detail in Chapter 4.

Micronutrients
Micronutrients are nutrients required by the body in lesser amounts, but are still essential for carrying out bodily functions.
Micronutrients include all the essential minerals and vitamins. There are sixteen essential minerals and thirteen vitamins (See Table
1.1 and Table 1.2 for a complete list and their major functions). In contrast to carbohydrates, lipids, and proteins, micronutrients are
not sources of energy (calories), but they assist in the process as cofactors or components of enzymes (i.e., coenzymes). Enzymes
are proteins that catalyze chemical reactions in the body and are involved in all aspects of body functions from producing energy, to
digesting nutrients, to building macromolecules. Micronutrients play many essential roles in the body.
Table 1.1 Minerals and Their Major Functions

Minerals Major Functions

Macro

Sodium Fluid balance, nerve transmission, muscle contraction

Chloride Fluid balance, stomach acid production

Potassium Fluid balance, nerve transmission, muscle contraction

Bone and teeth health maintenance, nerve transmission, muscle

Calcium
contraction, blood clotting

Phosphorus Bone and teeth health maintenance, acid-base balance

Magnesium Protein production, nerve transmission, muscle contraction

Sulfur Protein production

Trace

Iron Carries oxygen, assists in energy production

Protein and DNA production, wound healing, growth, immune

Zinc
system function

Iodine Thyroid hormone production, growth, metabolism

Selenium Antioxidant

Copper Coenzyme, iron metabolism

Manganese Coenzyme

Fluoride Bone and teeth health maintenance, tooth decay prevention

Chromium Assists insulin in glucose metabolism

Molybdenum Coenzyme

1.1.3 [Link]
Minerals
Minerals are solid inorganic substances that form crystals and are classified depending on how much of them we need. Trace
minerals, such as molybdenum, selenium, zinc, iron, and iodine, are only required in a few milligrams or less. Macrominerals, such
as calcium, magnesium, potassium, sodium, and phosphorus, are required in hundreds of milligrams. Many minerals are critical for
enzyme function, others are used to maintain fluid balance, build bone tissue, synthesize hormones, transmit nerve impulses,
contract and relax muscles, and protect against harmful free radicals in the body that can cause health problems such as cancer.

Vitamins
The thirteen vitamins are categorized as either water-soluble or fat-soluble. The water-soluble vitamins are vitamin C and all the B
vitamins, which include thiamine, riboflavin, niacin, pantothenic acid, pyridoxine, biotin, folate and cobalamin. The fat-soluble
vitamins are A, D, E, and K. Vitamins are required to perform many functions in the body such as making red blood cells,
synthesizing bone tissue, and playing a role in normal vision, nervous system function, and immune system function.
Table 1.2 Vitamins and Their Major Functions
Vitamins Major Functions

Water-soluble

Thiamin (B1) Coenzyme, energy metabolism assistance

Riboflavin (B2 ) Coenzyme, energy metabolism assistance

Niacin (B3) Coenzyme, energy metabolism assistance

Pantothenic acid (B5) Coenzyme, energy metabolism assistance

Pyridoxine (B6) Coenzyme, amino acid synthesis assistance

Biotin (B7) Coenzyme, amino acid and fatty acid metabolism

Folate (B9) Coenzyme, essential for growth

Cobalamin (B12) Coenzyme, red blood cell synthesis

C (ascorbic acid) Collagen synthesis, antioxidant

Fat-soluble

A Vision, reproduction, immune system function

D Bone and teeth health maintenance, immune system function

E Antioxidant, cell membrane protection

K Bone and teeth health maintenance, blood clotting

Vitamin deficiencies can cause severe health problems and even death. For example, a deficiency in niacin causes a disease called
pellagra, which was common in the early twentieth century in some parts of America. The common signs and symptoms of pellagra
are known as the “4D’s—diarrhea, dermatitis, dementia, and death.” Until scientists found out that better diets relieved the signs
and symptoms of pellagra, many people with the disease ended up hospitalized in insane asylums awaiting death. Other vitamins
were also found to prevent certain disorders and diseases such as scurvy (vitamin C), night blindness vitamin A, and rickets
(vitamin D).
Table 1.3 Functions of Nutrients

1.1.4 [Link]
 Necessary for tissue formation, cell reparation, and hormone and
Protein enzyme production. It is essential for building strong muscles and
a healthy immune system.

Provide a ready source of energy for the body and provide

Carbohydrates
structural constituents for the formation of cells.
Provides stored energy for the body, functions as structural
components of cells and also as signaling molecules for proper
Fat
cellular communication. It provides insulation to vital organs and
works to maintain body temperature.

Regulate body processes and promote normal body-system

Vitamins
functions.
Regulate body processes, are necessary for proper cellular
Minerals
function, and comprise body tissue.
Transports essential nutrients to all body parts, transports waste
Water products for disposal, and aids with body temperature
maintenance.

This page titled 1.1: Introduction is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper,
Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.
1.1: Introduction by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original source:
[Link]

1.1.5 [Link]
1.2: What Are Nutrients?
Learning Objective
Define the word “nutrient” and identify the six classes of nutrients essential for health.
List the three main energy (Calorie) yielding nutrients and how many Calories each of these nutrients provide.

What is in Food?
Your "diet" is defined as the foods you choose to eat. The diet of most people contains a variety of foods: nuts, seeds, leafy green
vegetables and more! The foods we eat contain nutrients. Nutrients are substances required by the body to perform its basic
functions. Nutrients must be obtained from diet, since the human body does not synthesize them, or does not synthesize them in
large enough amounts for human health. Nutrients are used for many body functions such as: growing, moving your muscles,
repairing tissues and much more! There are six classes of essential nutrients required for the body to function and maintain overall
health. These six classes of essential nutrients are: carbohydrates, lipids (fats), proteins, water, vitamins, and minerals. Foods also
contain non-nutrients. Some non-nutrients appear to be very important for human health, like fiber and antioxidants, some non-
nutrients may be harmful to human health such as: preservatives, colorings, flavorings and pesticide residues.

Figure : The Six Classes of Nutrients. Source:

[Link]

Macronutrients
Nutrients that are needed in large amounts are called macronutrients. There are three major classes of macronutrients:
carbohydrates, lipids, and proteins. All three of these nutrients are needed in relatively large amounts AND they contain Calories
(note the capital C which indicates kilocalories) which can be "burned" in your body to create energy for your body cells. The
energy from these macronutrients comes from their chemical bonds. This chemical energy is converted into cellular energy that is
then utilized to perform work, allowing our bodies to conduct their basic functions. A unit of measurement of food energy is the
Calorie. The next time you are eating a packaged food, look on the "Nutrition Facts" panel to find out how many Calories you
getting when you eat one serving of that food. Water is also a macronutrient in the sense that you require a large amount of it, but
unlike the other macronutrients it does not yield calories. One other possible component of the diet that can provide Calories is
alcohol though it is generally NOT considered to be a nutrient. Alcohol (in the form of ethanol) provides about 7 Calories per gram.

1.2.1 [Link]
 Figure : The Macronutrients:
Carbohydrates, Lipids, Protein, and Water

Carbohydrates
When you eat a food that contains carbohydrate, like bread for example, you will be receiving approximately 4 Calories for every
gram of carbohydrate you eat. Carbohydrates are molecules composed of carbon, hydrogen, and oxygen. The major food sources of
carbohydrates are grains, milk, fruits, and starchy vegetables like potatoes. Non-starchy vegetables also contain carbohydrates, but
in lesser quantities. Carbohydrates are broadly classified into two forms based on their chemical structure: fast-releasing
carbohydrates, often called "simple sugars", and slow-releasing carbohydrates, often called "complex carbohydrates".
Fast-releasing carbohydrates consist of one or two basic sugar units. They are sometimes called "simple sugars" because their
chemical structure is fairly simple with only one or two sugar units. If the carbohydrate has one sugar unit we call it a
"monosaccharide". Mono means one and saccharide means sugar. Examples of monosaccharides you have heard of are: Glucose
(the sugar that is in your blood); Fructose (a sugar commonly found in fruit); and Galactose (a sugar that is found as part of milk
sugar). If the carbohydrate has two sugar units we call it a "disaccharide". Di means two and saccharide means sugar. Examples of
disaccharides you may be familiar with are: sucrose (table sugar); lactose (milk sugar) and maltose (malt sugar). Sucrose is made of
a Glucose linked together with a Fructose. Lactose is made of Glucose linked together with Galactose. Maltose is made of two
Glucose molecules bonded together. In order to digest a disaccharide, your body has to break the two sugars apart. We will talk
more about this when we discuss lactose intolerance!
Slow-releasing carbohydrates are long chains of simple sugars (polysaccharides) that can be branched or unbranched. Some
polysaccharides that you have probably heard of are starch and fiber. During digestion, the body does its best to break down all
slow-releasing carbohydrates like starch to simple sugars, mostly glucose. Glucose is then transported to all our cells where it is
stored, used to make energy, or used to build macromolecules. Fiber is also a slow-releasing carbohydrate, but it cannot be broken
down in the human body and passes through the digestive tract undigested unless the bacteria that live in the large intestine break it
down for us.
One gram of carbohydrates yields four Calories of energy for the cells in the body to perform work. In addition to providing energy
and serving as building blocks for bigger macromolecules, carbohydrates are essential for proper functioning of the nervous
system, heart, and kidneys. As mentioned, glucose can be stored in the body for future use. In humans, the storage molecule of
carbohydrates is called glycogen and in plants it is known as starches. Glycogen and starches are slow-releasing carbohydrates.

Lipids
Lipids are also a family of molecules composed of carbon, hydrogen, and oxygen, but unlike carbohydrates, they are insoluble in
water. Lipids are found predominately in butter, oils, meats, dairy products, nuts, and seeds, and in many processed foods. The
three main types of lipids are triglycerides (triacylglycerols), phospholipids, and sterols. The main job of lipids is to store energy.

1.2.2 [Link]
Lipids provide more energy per gram than carbohydrates (nine Calories per gram of lipids versus four Calories per gram of
carbohydrates). In addition to energy storage, lipids serve as cell membranes, surround and protect organs, aid in temperature
regulation, and regulate many other functions in the body.

Proteins
Proteins are macromolecules composed of chains of subunits called amino acids. Amino acids are simple subunits composed of
carbon, oxygen, hydrogen, and nitrogen. The food sources of proteins are meats, dairy products, seafood, and a variety of different
plant-based foods, most notably soy. The word protein comes from a Greek word meaning “of primary importance,” which is an
apt description of these macronutrients; they are also known colloquially as the “workhorses” of life. Proteins provide four Calories
of energy per gram; however providing energy is not protein’s most important function. Proteins provide structure to bones,
muscles and skin, and play a role in conducting most of the chemical reactions that take place in the body. Scientists estimate that
greater than one-hundred thousand different proteins exist within the human body.

Water
There is one other nutrient that we must have in large quantities: water. Water does not contain carbon, but is composed of two
hydrogens and one oxygen per molecule of water. Water does not provide any Calories. More than 60 percent of your total body
weight is water. Without it, nothing could be transported in or out of the body, chemical reactions would not occur, organs would
not be cushioned, and body temperature would fluctuate widely. On average, an adult consumes just over two liters of water per
day from food and drink. According to the “rule of threes,” a generalization supported by survival experts, a person can survive
three minutes without oxygen, three days without water, and three weeks without food. Since water is so critical for life’s basic
processes, the amount of water input and output is supremely important, a topic we will explore in detail in Chapter 7.

Alcohol (not a nutrient)

Alcoholic drinks are a source of Calories even though they are generally not considered nutrients. Alcohol itself provides
approximately 7 Calories for every gram consumed. In addition to alcohol, many alcoholic drinks contain carbohydrate as well.

Micronutrients
Micronutrients are nutrients required by the body in lesser amounts, but are still essential for carrying out bodily functions.
Micronutrients include all the essential minerals and vitamins. There are sixteen essential minerals and thirteen vitamins (Tables
and for a complete list and their major functions). In contrast to carbohydrates, lipids, and proteins, micronutrients do not
contain Calories. This is often confusing because most people have heard how tired a person will feel if they are low in a
micronutrient such as Iron. The tiredness can be explained by the fact that, micronutrients assist in the process of making energy by
being part of enzymes (i.e., coenzymes). Enzymes catalyze chemical reactions in the body and are involved in many aspects of
body functions from producing energy, to digesting nutrients, to building macromolecules. Micronutrients play many roles in the
body.

Minerals
Minerals are solid inorganic substances that form crystals and are classified depending on how much of them we need. Trace
minerals, such as molybdenum, selenium, zinc, iron, and iodine, are only required in a few milligrams or less and macrominerals,
such as calcium, magnesium, potassium, sodium, and phosphorus, are required in hundreds of milligrams. Many minerals are
critical for enzyme function, others are used to maintain fluid balance, build bone tissue, synthesize hormones, transmit nerve
impulses, contract and relax muscles, and protect against harmful free radicals.
Table : : Minerals and Their Major Functions

1.2.3 [Link]
 Minerals Major Functions

Macro

Sodium Fluid balance, nerve transmission, muscle contraction

Chloride Fluid balance, stomach acid production

Potassium Fluid balance, nerve transmission, muscle contraction

Bone and teeth health maintenance, nerve transmission, muscle

Calcium
contraction, blood clotting

Phosphorus Bone and teeth health maintenance, acid-base balance

Magnesium Protein production, nerve transmission, muscle contraction

Sulfur Protein production

Trace

Iron Carries oxygen, assists in energy production

Protein and DNA production, wound healing, growth, immune

Zinc
system function

Iodine Thyroid hormone production, growth, metabolism

Selenium Antioxidant

Copper Coenzyme, iron metabolism

Manganese Coenzyme

Fluoride Bone and teeth health maintenance, tooth decay prevention

Chromium Assists insulin in glucose metabolism

Molybdenum Coenzyme

Vitamins
The thirteen vitamins are categorized as either water-soluble or fat-soluble. The water-soluble vitamins are vitamin C and all the B
vitamins, which include thiamine, riboflavin, niacin, pantothenic acid, pyroxidine, biotin, folate and cobalamin. The fat-soluble
vitamins are A, D, E, and K. Vitamins are required to perform many functions in the body such as making red blood cells,
synthesizing bone tissue, and playing a role in normal vision, nervous system function, and immune system function.
Table : Vitamins and Their Major Functions

1.2.4 [Link]
 Vitamins Major Functions

Water-soluble

B1 (thiamine) Coenzyme, energy metabolism assistance

B2 (riboflavin) Coenzyme, energy metabolism assistance

B3 (niacin) Coenzyme, energy metabolism assistance

B5 (pantothenic acid) Coenzyme, energy metabolism assistance

B6 (pyroxidine) Coenzyme, amino acid synthesis assistance

Biotin Coenzyme

Folate Coenzyme, essential for growth

B12 (cobalamin) Coenzyme, red blood cell synthesis

C Collagen synthesis, antioxidant

Fat-soluble

A Vision, reproduction, immune system function

D Bone and teeth health maintenance, immune system function

E Antioxidant, cell membrane protection

K Bone and teeth health maintenance, blood clotting

Vitamin deficiencies can cause severe health problems. For example, a deficiency in niacin causes a disease called pellagra, which
was common in the early twentieth century in some parts of America. The common signs and symptoms of pellagra are known as
the “4D’s—diarrhea, dermatitis, dementia, and death.” Until scientists found out that better diets relieved the signs and symptoms
of pellagra, many people with the disease ended up in insane asylums awaiting death (Video ). Other vitamins were also found
to prevent certain disorders and diseases such as scurvy (vitamin C), night blindness (vitamin A), and rickets (vitamin D).

pellagra video

Video : This video provides a brief history of Dr. Joseph Goldberger’s

discovery that pellagra was a diet-related disease.

Food Energy
Though this is only Chapter 1, you have already seen the words "Calories" and "Energy" used several times. In everyday life you
have probably heard people talk about how many Calories they burned on the treadmill or how many Calories are listed on a bag of
chips. Calories, are a measure of energy. It takes quite a lot of Calories (energy) to keep us alive. Even if a person is in a coma, they
still burn approximately 1000 Calories of energy in order for: their heart to beat, their blood to circulate, their lungs to breathe,

1.2.5 [Link]
etc... We burn even more calories when we exercise. The carbohydrates, fats and proteins we eat and drink provide calories for us
(and alcohol as well if we choose to consume it). Sometimes people refer to these nutrients as "energy yielding". As you read
above, carbohydrates provide 4 Calories for every gram we consume; proteins provide 4 Calories for every gram we consume; fats
provide 9 Calories for every gram we consume and alcohol provides 7 Calories of energy for every gram we consume. Vitamins,
minerals and water do not provide any calories, even though they are still essential nutrients.

Food Quality: Nutrient Density compared to Calorie Density

One way to think about the quality of your food is to consider how many nutrients you receive from a serving of that food
compared to the number of Calories you receive from one serving of the food. For example, a candy bar gives you quite a few
Calories but not very many of the essential nutrients. We would say that the candy bar has Calorie density but low Nutrient density.
An apple on the other hand, has quite a few essential nutrients but not very many Calories. We would say that the apple has high
Nutrient density but low Calorie density.
Please watch the following Ted Ed video called "What is a Calorie" which will describe in more detail what a Calorie is and why
you may want to know how many Calories you are consuming compared to how many you are burning each day.

What is a calorie? - Emma Bryce

Video: What is a calorie? - Emma Bryce

One measurement of food quality is the amount of nutrients it contains relative to the amount of energy (Calories) it provides.
High-quality foods are nutrient dense, meaning they contain lots of the nutrients relative to the amount of Calories they provide.
Nutrient-dense foods are the opposite of “empty-calorie” foods such as carbonated sugary soft drinks, which provide many calories
and very little, if any, other nutrients. Food quality is additionally associated with its taste, texture, appearance, microbial content,
and how much consumers like it.

Food: A Better Source of Nutrients

It is better to get all your micronutrients from the foods you eat as opposed to from supplements. Supplements contain only
what is listed on the label, but foods contain many more macronutrients, micronutrients, and other chemicals, like antioxidants
that benefit health. While vitamins, multivitamins, and supplements are a $20 billion industry in this country and more than 50
percent of Americans purchase and use them daily, there is no consistent evidence that they are better than food in promoting
health and preventing disease. Dr. Marian Neuhouser, associate of the Fred Hutchinson Cancer Research Center in Seattle, says
that “…scientific data are lacking on the long-term health benefits of supplements. To our surprise, we found that
multivitamins did not lower the risk of the most common cancers and also had no impact on heart disease. ”Woodward, K.
“Multivitamins Each Day Will Not Keep Common Cancers Away; Largest Study of Its Kind Provides Definitive Evidence that
Multivitamins Will Not Reduce Risk of Cancer or Heart Disease in Postmenopausal Women.” Fred Hutchinson Cancer
Research Center. Center News 16 (February 2009).
[Link]

1.2.6 [Link]
Key Takeaways
Foods contain nutrients that are essential for our bodies to function.
Four of the classes of nutrients required for bodily function are needed in large amounts. They are carbohydrates, lipids,
proteins, and water, and are referred to as macronutrients.
Two of the classes of nutrients are needed in lesser amounts, but are still essential for bodily function. They are vitamins and
minerals.
One measurement of food quality is the amount of essential nutrients a food contains relative to the amount of energy it has
(nutrient density).

Discussion Starters
1. Make a list of some of your favorite foods and visit the “What’s In the Foods You Eat?” search tool provided by the USDA.
What are some of the nutrients found in your favorite foods?
[Link]
2. Have a discussion in class on the “progression of science” and its significance to human health as depicted in the video on
pellagra (Video .

1.2: What Are Nutrients? is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

1.2.7 [Link]
1.3: Food Quality
One measurement of food quality is the amount of nutrients it contains relative to the amount of energy it provides. High-quality
foods are nutrient-dense, meaning they contain significant amounts of one or more essential nutrients relative to the amount of
calories they provide. Nutrient-dense foods are the opposite of “empty-calorie” foods such as carbonated sugary soft drinks, which
provide many calories and very little, if any, other nutrients. Food quality is additionally associated with its taste, texture,
appearance, microbial content, and how much consumers like it.

Figure : Image by David De Veroli on [Link] / CC0

Food: A Better Source of Nutrients

It is better to get all your micronutrients from the foods you eat as opposed to from supplements. Supplements contain only what is
listed on the label, but foods contain many more macronutrients, micronutrients, and other chemicals, like antioxidants, that benefit
health. While vitamins, multivitamins, and supplements are a $20 billion industry in the United States, and more than 50 percent of
Americans purchase and use them daily, there is no consistent evidence that they are better than food in promoting health and
preventing disease.

 Everyday Connection

Make a list of some of your favorite foods and visit the “What’s In the Foods You Eat?” search tool provided by the USDA.
What are some of the nutrients found in your favorite foods?

Figure : USDA

This page titled 1.3: Food Quality is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper,
Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.
1.2: Food Quality by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original source:
[Link]

1.3.1 [Link]
1.4: Units of Measure
In nutrition, there are two systems of commonly used measurements: Metric and US Customary. We need both because the US
won’t adopt the metric system completely.

The Metric and US Customary System

These are commonly used prefixes for the Metric System:

Micro- (μ) 1/1,000,000th (one millionth)

Milli- (m) 1/1000th (one thousandth)

Centi- (c) 1/100th (one hundredth)

Deci- (d) 1/10th (one tenth)

Kilo- (k) 1000x (one thousand times)

Mass
Metric System US Customary System Conversions

Microgram (μg) Ounce (oz) 1 oz = 28.35 g

Milligram (mg) Pound (lb) 1 lb = 16 oz

Gram (g) 1 lb = 454 g

Kilogram (kg) 1 kg = 2.2 lbs

Volume
Metric System US Customary System Conversions

Milliliter (mL) Teaspoon (tsp) 1 tsp = 5 mL

Deciliter (dL) Tablespoon (tbsp) 1 tbsp = 3 tsp = 15 mL

Liter (L) Fluid ounce (fl oz) 1 fl oz = 2 tbsp = 30 mL

Cup (c) 1 c = 8 fl oz = 237 mL

Pint (pt) 1 pt = 2 c = 16 fl oz

Quart (qt) 1 qt = 4 c = 32 fl oz = 0.95 L

Gallon (gal) = 4 qt 1 gal = 4 qt

Length
Metric System US Customary System Conversions

Millimeter (mm) Inch (in) 1 in = 25.4 mm

Centimeter (cm) Foot (ft) 1 ft= 30.5 cm

Meter (m) Yard (yd) 1 yd = 0.9 m

Kilometer (km) Mile (mi) 1 mi = 1.6 km

This page titled 1.4: Units of Measure is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper,
Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.

1.4.1 [Link]
1.3: Units of Measure by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original
source: [Link]

1.4.2 [Link]
1.5: The Broad Role of Nutritional Science
Learning Objective
Provide an example of how the scientific method works to promote health and prevent disease.

How to Determine the Health Effects of Food and Nutrients

Similar to the method by which a police detective finally charges a criminal with a crime, nutritional scientists discover the health
effects of food and its nutrients by first making an observation. Once observations are made, they come up with a hypothesis, test
their hypothesis, and then interpret the results. After this, they gather additional evidence from multiple sources and finally come up
with a conclusion on whether the food suspect fits the claim. This organized process of inquiry used in forensic science, nutritional
science, and every other science is called the scientific method.
Below is an illustration of the scientific method at work—in this case to prove that iodine is a nutrient. Zimmerman, M.B.
“Research on Iodine Deficiency and Goiter in the 19th and Early 20th Centuries.” J Nutr 138, no. 11 (November 2008): 2060–63.
Carpenter, K.J. “David Marine and the Problem of Goiter.” J Nutr 135, no.4 (April 2005): 675–80. In 1811, French chemist
Bernard Courtois was isolating saltpeter for producing gunpowder to be used by Napoleon’s army. To carry out this isolation he
burned some seaweed and in the process observed an intense violet vapor that crystallized when he exposed it to a cold surface. He
sent the violet crystals to an expert on gases, Joseph Gay-Lussac, who identified the crystal as a new element. It was named iodine,
the Greek word for violet. The following scientific record is some of what took place in order to conclude that iodine is a nutrient.
Observation. Eating seaweed is a cure for goiter, a gross enlargement of the thyroid gland in the neck.
Hypothesis. In 1813, Swiss physician Jean-Francois Coindet hypothesized that the seaweed contained iodine and he could use
just iodine instead of seaweed to treat his patients.
Experimental test. Coindet administered iodine tincture orally to his patients with goiter.
Interpret results. Coindet’s iodine treatment was successful.
Gathering more evidence. Many other physicians contributed to the research on iodine deficiency and goiter.
Hypothesis. French chemist Chatin proposed that the low iodine content in food and water of certain areas far away from the
ocean were the primary cause of goiter and renounced the theory that goiter was the result of poor hygiene.
Experimental test. In the late 1860s the program, “The stamping-out of goiter,” started with people in several villages in
France being given iodine tablets.
Results. The program was effective and 80 percent of goitrous children were cured.
Hypothesis. In 1918, Swiss doctor Bayard proposed iodizing salt as a good way to treat areas endemic with goiter.
Experimental test. Iodized salt was transported by mules to a small village at the base of the Matterhorn where more than 75
percent of school children were goitrous. It was given to families to use for six months.
Results. The iodized salt was beneficial in treating goiter in this remote population.
Experimental test. Physician David Marine conducted the first experiment of treating goiter with iodized salt in America in
Akron, Ohio.
Results. This study conducted on over four-thousand school children found that iodized salt prevented goiter.
Conclusions. Seven other studies similar to Marine’s were conducted in Italy and Switzerland that also demonstrated the
effectiveness of iodized salt in treating goiter. In 1924, US public health officials initiated the program of iodizing salt and
started eliminating the scourge of goiterism. Today more than 70 percent of American households use iodized salt and many
other countries have followed the same public health strategy to reduce the health consequences of iodine deficiency.

Evidence-Based Approach to Nutrition

It took more than one hundred years from iodine’s discovery as an effective treatment for goiter until public health programs
recognized it as such. Although a lengthy process, the scientific method is a productive way to define essential nutrients and
determine their ability to promote health and prevent disease. The scientific method is part of the overall evidence-based approach
to designing nutritional guidelines. An evidence-based approach to nutrition includes:Briss, P.A., et al. “Developing an Evidence-
Based Guide to Community Preventive Services—Methods.” Am J Prev Med 18, no. 1S (2000): 35–43., Myers, E. “Systems for

1.5.1 [Link]
Evaluating Nutrition Research for Nutrition Care Guidelines: Do They Apply to Population Dietary Guidelines?” J Am Diet Assoc
103, no. 12, supplement 2 (December 2003): 34–41.
Defining the problem or uncertainty (e.g., the rate of colon cancer is higher in people who eat red meat)
Formulating it as a question (e.g., Does eating red meat contribute to colon cancer?)
Setting criteria for quality evidence
Evaluating the body of evidence
Summarizing the body of evidence and making decisions
Specifying the strength of the supporting evidence required to make decisions
Disseminating the findings
The Food and Nutrition Board of the Institute of Medicine, a nonprofit, nongovernmental organization, constructs its nutrient
recommendations (i.e., Dietary Reference Intakes, or DRI) using an evidence-based approach to nutrition. The entire procedure for
setting the DRI is documented and made available to the public. The same approach is used by the USDA and HHS, which are
departments of the US federal government. The USDA and HHS websites are great tools for discovering ways to optimize health;
however, it is important to gather nutrition information from multiple resources as there are often differences in opinion among
various scientists and public health organizations. While the new Dietary Guidelines, published in 2015, have been well-received
by some, there are nongovernmental public health organizations that are convinced that some pieces of the guidelines may be
influenced by lobbying groups and/or the food industry. For example, the Harvard School of Public Health (HSPH) feels the
government falls short by being “too lax on refined grains.”The guidelines recommend getting at least half of grains from whole
grains—according to the HSPH this still leaves too much consumption of refined grains.
For a list of reliable sources that advocate good nutrition to promote health and prevent disease using evidence-based science see
Table . In subsquent sections, we will further discuss distinguishing criteria that will enable you to wade through misleading
nutrition information and instead gather your information from reputable, credible websites and organizations.
Table : Web Resources for Nutrition and Health

1.5.2 [Link]
 Organization Website

Governmental

US Department of Agriculture [Link]

USDA Center for Nutrition Policy and Promotion [Link]/

US Department of Health and Human Services [Link]

Centers for Disease Control and Prevention [Link]

Food and Drug Administration [Link]

Healthy People [Link]

Office of Disease Prevention and Health Promotion [Link]/

Health Canada [Link]

International

World Health Organization [Link]

Food and Agricultural Organization of the United Nations [Link]/

Nongovernmental

Harvard School of Public Health [Link]/nutritio...rce/[Link]

Mayo Clinic [Link]

Linus Pauling Institute [Link]

American Society for Nutrition [Link]

American Medical Association [Link]

American Diabetes Association [Link]

The Academy of Nutrition and Dietetics [Link]

Institute of Medicine: Food and Nutrition [Link]/Global/Topics/[Link]

Dietitians of Canada [Link]

Types of Scientific Studies

There are many types of scientific studies that can be used to provide supporting evidence for a particular hypothesis. The various
types of studies include epidemiological studies, interventional clinical trials, and randomized clinical interventional trials.
Epidemiological studies are observational studies that look for health patterns and are often the front-line studies for public health.
The CDC defines epidemiological studies as scientific investigations that define frequency, distribution, and patterns of health
events in a population. Thus, these studies describe the occurrence and patterns of health events over time. The goal of an
epidemiological study is to find factors associated with an increased risk for a health event, though these sometimes remain elusive.
An example of an epidemiological study is the Framingham Heart Study, a project of the National Heart, Lung and Blood Institute
and Boston University that has been ongoing since 1948. This study first examined the physical health and lifestyles of 5,209 men
and women from the city of Framingham, Massachusetts and has now incorporated data from the children and grandchildren of the
original participants. One of the seminal findings of this ambitious study was that higher cholesterol levels in the blood are a risk
factor for heart disease. The Framingham Heart Study, a project of the National Heart, Lung, and Blood Institute and Boston
University. “History of the Framingham Heart Study.” Epidemiological studies are a cornerstone for examining and evaluating
public health and some of their advantages are that they can lead to the discovery of disease patterns and risk factors for diseases,
and they can be used to predict future healthcare needs and provide information for the design of disease prevention strategies for

1.5.3 [Link]
entire populations. Some shortcomings of epidemiological studies are that investigators cannot control environments and lifestyles,
a specific group of people studied may not be an accurate depiction of an entire population, and these types of scientific studies
cannot directly determine if one variable causes another. Scientists regard epidemiological studies as a starting place for ideas about
what types of lifestyle choice MAY contribute to a disease. They can show a correlation between two things happening but not
whether one factor CAUSED the other. My favorite example of this is a thought experiment where a make-believe scientist
observes (through epidemiological studies) that grey hair often goes along with Alzheimer's Disease. Wouldn't it be silly for that
scientist to predict that grey hair CAUSES Alzheimer's Disease? Could that scientist easily test that silly prediction? Suppose that
scientist dyed a group of people's hair grey to see if the color grey truly increased their risk of Alzheimer's Disease. The whole
thing is silly but I think you get the point. Epidemiological studies may give us ideas but those ideas need clinical trials to figure
out what the patterns mean.
Interventional clinical trial studies are scientific investigations in which a variable is changed between groups of people. When well
done, this type of study allows one to determine causal relationships. An example of an interventional clinical trial study is the
Dietary Approaches to Stop Hypertension (DASH) trial published in the April 1997 issue of The New England Journal of
[Link], L. J., et al. “A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure.,” N Engl J Med 336 (April
1997): 1117–24. In this study, 459 people were randomly assigned to three different groups; one was put on an average American
control diet, a second was put on a diet rich in fruits and vegetables, and the third was put on a combination diet rich in fruits,
vegetables, and low-fat dairy products with reduced saturated and total fat intake. The groups remained on the diets for eight
weeks. Blood pressures were measured before starting the diets and after eight weeks. Results of the study showed that the group
on the combination diet had significantly lower blood pressure at the end of eight weeks than those who consumed the control diet.
The authors concluded that the combination diet is an effective nutritional approach to treat high blood pressure. The attributes of
high-quality clinical interventional trial studies are:
those that include a control group, which does not receive the intervention, to which you can compare the people who receive
the intervention being tested;
those in which the subjects are randomized into the group or intervention group, meaning a given subject has an equal chance of
ending up in either the control group or the intervention group. This is done to ensure that any possible confounding variables
are likely to be evenly distributed between the control and the intervention groups;
those studies that include a sufficient number of participants.
What are confounding variables? These are factors other than the one being tested that could influence the results of the study. For
instance, in the study we just considered, if one group of adults did less physical activity than the other, then it could be the amount
of physical activity rather than the diet being tested that caused the differences in blood pressures among the groups.
The limitations of these types of scientific studies are that they are difficult to carry on for long periods of time, are costly, and
require that participants remain compliant with the intervention. Furthermore, it is unethical to study certain interventions. (An
example of an unethical intervention would be to advise one group of pregnant mothers to drink alcohol to determine the effects of
alcohol intake on pregnancy outcome, because we know that alcohol consumption during pregnancy damages the developing
fetus.)
Randomized clinical interventional trial studies are powerful tools to provide supporting evidence for a particular relationship and
are considered the “gold standard” of scientific studies. A randomized clinical interventional trial is a study in which participants
are assigned by chance to separate groups that compare different treatments. Neither the researchers nor the participants can choose
which group a participant is assigned. However, from their limitations it is clear that epidemiological studies complement
interventional clinical trial studies and both are necessary to construct strong foundations of scientific evidence for health
promotion and disease prevention.
Other scientific studies used to provide supporting evidence for a hypothesis include laboratory studies conducted on animals or
cells. An advantage of this type of study is that they typically do not cost as much as human studies and they require less time to
conduct. Other advantages are that researchers have more control over the environment and the amount of confounding variables
can be significantly reduced. Moreover, animal and cell studies provide a way to study relationships at the molecular level and are
also helpful in determining the exact mechanism by which a specific nutrient causes a change in health. The disadvantage of these
types of studies are that researchers are not working with whole humans and thus the results may not be relevant. Nevertheless,

1.5.4 [Link]
well-conducted animal and cell studies that can be repeated by multiple researchers and obtain the same conclusion are definitely
helpful in building the evidence to support a scientific hypothesis.

Evolving Science
Science is always moving forward, albeit sometimes slowly. One study is not enough to make a guideline or a recommendation or
cure a disease. Science is a stepwise process that builds on past evidence and finally culminates into a well-accepted conclusion.
Unfortunately, not all scientific conclusions are developed in the interest of human health and it is important to know where a
scientific study was conducted and who provided the money. Indeed, just as an air quality study paid for by a tobacco company
diminishes its value in the minds of readers, so does one on red meat performed at a laboratory funded by a national beef
association.
Science can also be contentious even amongst experts that don’t have any conflicting financial interests. To see scientists debating
over the nutritional guidelines, watch Video \(\PageIndex{1}\. Contentious science is actually a good thing as it forces researchers
to be of high integrity, well-educated, well-trained, and dedicated. It also instigates public health policy makers to seek out multiple
sources of evidence in order to support a new policy. Agreement involving many experts across multiple scientific disciplines is
necessary for recommending dietary changes to improve health and prevent disease. Although a somewhat slow process, it is better
for our health to allow the evidence to accumulate before incorporating some change in our diet.

Boosting Vitamin D: Not Enough Or Too …

Video : Debate" This webcast from March 29, 2011 demonstrates how
science is always evolving and how debate among nutrition science experts
influences policy [Link]: Harvard School of Public Health, in
collaboration with Reuters.

Nutritional Science Evolution

One of the newest areas in the realm of nutritional science is the scientific discipline of nutritional genetics, also called
nutrigenomics. Genes are part of DNA and contain the genetic information that make up all our traits. Genes are codes for proteins
and when they are turned “on” or “off,” they change how the body works. While we know that health is defined as more than just
the absence of disease, there are currently very few accurate genetic markers of good health. Rather, there are many more genetic
markers for disease. However, science is evolving and nutritional genetics aims to identify what nutrients to eat to “turn on”
healthy genes and “turn off” genes that cause disease. Eventually this field will progress so that a person’s diet can be tailored to
their genetics. Thus, your DNA will determine your optimal diet.

1.5.5 [Link]
 Video : Nutrigenomics: A dietitian describes the new scientific discipline
of nutrigenomics and its potential impact on diet and health.

Using Science and Technology to Change the Future

As science evolves, so does technology. Both can be used to create a healthy diet, optimize health, and prevent disease. Picture
yourself not too far into the future: you are wearing a small “dietary watch” that painlessly samples your blood, and downloads the
information to your cell phone, which has an app that evaluates the nutrient profile of your blood and then recommends a snack or
dinner menu to assure you maintain adequate nutrient levels. What else is not far off? How about another app that provides a
shopping list that adheres to all dietary guidelines and is emailed to the central server at your local grocer who then delivers the
food to your home? The food is then stored in your smart fridge which documents your daily diet at home and delivers your weekly
dietary assessment to your home computer (Figure :. At your computer, you can compare your diet with other diets aimed at
weight loss, optimal strength training, reduction in risk for specific diseases or any other health goals you may have. You may also
delve into the field of nutritional genetics and download your gene expression profiles to a database that analyzes yours against
millions of others.

Figure : The “Smart Fridge". (CC BY 2.0;

David Berkowitz)

Key Takeaways
The scientific method is an organized process of inquiry used in nutritional science to determine if the food suspect fits the
claim.
The scientific method is part of the overall evidence-based approach to designing nutritional guidelines that are based on facts.
There are different types of scientific studies—epidemiological studies, randomized clinical interventional trial studies, and
laboratory animal and cell studies—which all provide different, complementary lines of evidence.
It takes time to build scientific evidence that culminates as a commonly accepted conclusion.

1.5.6 [Link]
 Agreement of experts across multiple scientific disciplines is a necessity for recommending dietary changes to improve health
and help to prevent disease.
Science is always evolving as more and more information is collected.

Discussion Starters
1. What are some of the ways in which you think like a scientist and use the scientific method in your everyday life? Any
decision-making process uses at least pieces of the scientific method. Think about some of the major decisions you have made
in your life and the research you conducted that supported your decision. For example, what computer brand do you own?
Where is your money invested? What college do you attend?
2. Do you use technology, appliances, and/or apps that help you to optimize your health?

1.5: The Broad Role of Nutritional Science is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

1.5.7 [Link]
1.6: Research and the Scientific Method

ask more questions signage [Link]

Nutritional scientists discover the health effects of food and its nutrients by first making an observation. Once observations are
made, they come up with a hypothesis, test their hypothesis, and then interpret the results. After this, they gather additional
evidence from multiple sources and finally come up with a conclusion. This organized process of inquiry used in science is called
the scientific method.

Figure 1.2 Scientific Method Steps. Scientific

Method steps
In 1811, French chemist Bernard Courtois was isolating saltpeter for producing gunpowder to be used by Napoleon’s army. To
carry out this isolation, he burned some seaweed and in the process, observed an intense violet vapor that crystallized when he
exposed it to a cold surface. He sent the violet crystals to an expert on gases, Joseph Gay-Lussac, who identified the crystal as a
new element. It was named iodine, the Greek word for violet. The following scientific record is some of what took place in order to
conclude that iodine is a nutrient.
Observation. Eating seaweed is a cure for goiter, a gross enlargement of the thyroid gland in the neck.

1.6.1 [Link]
Hypothesis. In 1813, Swiss physician Jean-Francois Coindet hypothesized that the seaweed contained iodine, and that iodine could
be used instead of seaweed to treat his patients[1].
Experimental test. Coindet administered iodine tincture orally to his patients with goiter.
Interpret results. Coindet’s iodine treatment was successful.
Hypothesis. French chemist Chatin proposed that the low iodine content in food and water in certain areas far away from the ocean
was the primary cause of goiter, and renounced the theory that goiter was the result of poor hygiene.
Experimental test. In the late 1860s the program, “The stamping-out of goiter,” started with people in several villages in France
being given iodine tablets.
Results. The program was effective and 80 percent of goitrous children were cured.
Hypothesis. In 1918, Swiss doctor Bayard proposed iodizing salt as a good way to treat areas endemic with goiter.
Experimental test. Iodized salt was transported by mules to a small village at the base of the Matterhorn where more than 75
percent of school children were goitrous. It was given to families to use for six months.
Results. The iodized salt was beneficial in treating goiter in this remote population.
Experimental test. Physician David Marine conducted the first experiment of treating goiter with iodized salt in America in Akron,
Ohio.[2]
Results. This study was conducted on over four-thousand school children, and found that iodized salt prevented goiter.
Conclusions. Seven other studies similar to Marine’s were conducted in Italy and Switzerland, which also demonstrated the
effectiveness of iodized salt in treating goiter. In 1924, US public health officials initiated the program of iodizing salt and started
eliminating the scourge of goiter. Today, more than 70% of American households use iodized salt and many other countries have
followed the same public health strategy to reduce the health consequences of iodine deficiency.

 Career Connection

What are some of the ways in which you think like a scientist, and use the scientific method in your everyday life? Any
decision-making process uses some aspect of the scientific method. Think about some of the major decisions you have made in
your life and the research you conducted that supported your decision. For example, what brand of computer do you own?
Where is your money invested? What college do you attend?

Evidence-Based Approach to Nutrition

It took more than one hundred years from iodine’s discovery as an effective treatment for goiter until public health programs
recognized it as such. Although a lengthy process, the scientific method is a productive way to define essential nutrients and
determine their ability to promote health and prevent disease. The scientific method is part of the overall evidence-based approach
to designing nutritional guidelines[3]. An evidence-based approach to nutrition includes[4]:
Defining the problem or uncertainty (e.g., the incidence of goiter is lower in people who consume seaweed)
Formulating it as a question (e.g., Does eating seaweed decrease the risk of goiter?)
Setting criteria for quality evidence
Evaluating the body of evidence
Summarizing the body of evidence and making decisions
Specifying the strength of the supporting evidence required to make decisions
Disseminating the findings
The Food and Nutrition Board of the Institute of Medicine, a nonprofit, non-governmental organization, constructs its nutrient
recommendations (i.e., Dietary Reference Intakes, or DRI) using an evidence-based approach to nutrition. The entire procedure for
setting the DRI is documented and made available to the public. The same approach is used by the USDA and HHS, which are
departments of the US federal government. The USDA and HHS websites are great tools for discovering ways to optimize health;
however, it is important to gather nutrition information from multiple resources, as there are often differences in opinion among

1.6.2 [Link]
various scientists and public health organizations. Full text versions of the DRI publications are available in pdf format at
[Link] along with many other free publications.
1. Zimmerman, M.B. (2008). Research on Iodine Deficiency and Goiter in the 19th and Early 20th Centuries. Journal of Nutrition,
138(11), 2060–63. [Link]/content/138/11/[Link]↵
2. Carpenter, K.J. (2005). David Marine and the Problem of Goiter. Journal of Nutrition, 135(4), 675–80.
[Link]/content/135/...=d06fdd35-566f -42a2-a3fd- efbe0736b7ba ↵
3. Myers E. (2003). Systems for Evaluating Nutrition Research for Nutrition Care Guidelines: Do They Apply to Population
Dietary Guidelines? Journal of the American Dietetic Association, 12(2), 34–41. [Link]
8223(03)01378-6/abstract↵
4. Briss PA, Zara S, et al. (2000). Developing an Evidence-Based Guide to Community Preventive Services—Methods. Am J Prev
Med, 18(1S), 35–43. [Link]

This page titled 1.6: Research and the Scientific Method is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated
by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
1.6: Research and the Scientific Method by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA
4.0. Original source: [Link]

1.6.3 [Link]
 CHAPTER OVERVIEW

2: Achieving a Healthy Diet

In this chapter, we explore the tools you can use to achieve a healthy diet, as well as important nutrition concepts like balance and
moderation.
2.1: Chapter Introduction
2.2: A Healthy Philosophy toward Food
2.3: What Is Nutritional Balance and Moderation?
2.4: National Goals for Nutrition and Health- Healthy People 2020
2.5: Recommendations for Optimal Health
2.6: Understanding Dietary Reference Intakes (DRI)
2.7: Understanding the Bigger Picture of Dietary Guidelines
2.8: Discovering Nutrition Facts
2.9: Building Healthy Eating Patterns
2.10: When Enough is Enough
2.11: Nutrition and the Media

Template:HideTOC

2: Achieving a Healthy Diet is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

1
2.1: Chapter Introduction
The dietary toolkit contains numerous ideas to help you achieve a healthy diet.
Let’s talk about a toolkit for a healthy diet. The first thing in it would be the Recommended Daily Allowances (RDAs). Then we
could add the Dietary Reference Intakes (DRIs), the Estimated Average Requirements (EARs), and the Tolerable Upper Limits
(ULs). All of these tools are values for important nutrients, calculated to meet the health needs of different age groups. But long
before the dietary toolkit full of acronyms such as DRI, RDA, EAR, and UL, daily standards were created with the single goal of
keeping workers alive and toiling in the factories and workhouses of the early Industrial Revolution. In the late nineteenth century
powerhouse tycoons operated without fear of legal consequences and paid their workers as little as possible in order to maximize
their own profits. Workers could barely afford housing, and depended on what their bosses fed them at the workhouses to fend off
starvation.

Figure : Without programs like food stamps, workers and military

personnel often had to accept whatever meager rations were given to them by their employers. People eating at a soup kitchen.
Montreal, Canada. Public domain image.
Living conditions in those days show that the term “starvation wages” was not just a figure of speech. Here’s a typical day’s menu:
Breakfast. 1 pint porridge, one 6-ounce piece of bread.
Lunch. Beef broth one day, boiled pork and potatoes the next.
Dinner. 1 pint porridge, one 6-ounce piece of bread.
As public awareness about these working conditions grew, so did public indignation. Experts were eventually called in to create the
first dietary guidelines, which were designed only to provide a typical individual with what they needed to survive each day, and no
more. It wasn’t until World War I that the British Royal Society first made recommendations about the nutrients people needed to
be healthy, as opposed to merely surviving. They included ideas we now take for granted, such as making fruit and vegetables part
of the diet and giving milk to children. Since then, most governments have established their own dietary standards. Food is a
precious commodity, like energy, and controlling the way it is distributed confers power. Sometimes this power is used to influence
other countries, as when the United States withholds food aid from countries with regimes of which it disapproves. Governments
can also use their power over food to support their most fragile citizens with food relief programs, such as the Supplemental
Nutrition Assistance Program (SNAP) and the Women, Infants, and Children Supplemental Food Program (WIC).
The US government has also established dietary standards to help citizens follow a healthy diet. The first of these were the
Recommended Daily Allowances (RDAs), published in 1943 because of the widespread food shortages caused by World War II.
During the war, the government rationed sugar, butter, milk, cheese, eggs, coffee, and canned goods. Limited transportation made it
hard to distribute fruits and vegetables. To solve this problem, the government encouraged citizens to plant “victory gardens” to
produce their own fruits and vegetables. More than twenty million people began planting gardens in backyards, empty lots, and on
rooftops. Neighbors pooled their resources and formed cooperatives, planting in the name of patriotism.

2.1.1 [Link]
 Figure : A key part of the former First Lady Michelle Obama’s healthy eating campaign is the new
My Food Plate. Official portrait of First Lady Michelle Obama in the Green Room of the White House. Unfortunately from a
nutrition perspective, regulations put in place to advance nutrition in school children's diets have been rolled back by the
subsequent administration.
Today in the United States, there are various measures used to maintain access to nutritious, safe, and sufficient food to the
citizenry. Many of these dietary guidelines are provided by the government, and are found at the Food and Drug Administration’s
(FDA) new website, [Link]. We call this collection of guidelines the “dietary toolkit.”

How will you use the dietary toolkit?

The government works to provide citizens with information, guidance, and access to healthy foods. How will you decide which
information to follow? What are the elements of a healthy diet, and how do you figure out ways to incorporate them into your
personal diet plan? The dietary toolkit can be likened to a mechanics toolkit, with every tool designed for a specific task(s).
Likewise, there are many tools in the dietary toolkit that can help you build, fix, or maintain your diet for good health. In this
chapter you will learn about many of the tools available to you.

Figure : Today, the US government sets dietary guidelines that provide

evidence-based nutrition information designed to improve the health of the population. Source: US Department of Agriculture.

2.1: Chapter Introduction is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

2.1.2 [Link]
2.2: A Healthy Philosophy toward Food
Learning Objectives
Explain why nutrition is important to health.

“Tell me what you eat, and I will tell you what you are” wrote the French lawyer and politician, Antheime Brillat-Savarin in his
book, Physiologie du Gout, ou Meditations de Gastronomie Transcendante, in 1826. Almost one hundred years later, nutritionist
Victor Lindlahr wrote in an ad in 1923, “Ninety percent of the diseases known to man are caused by cheap foodstuffs. You are what
you eat.” Today, we know this phrase simply as, “You are what you eat.”

Figure : Nutrition provides the body with the nutrients it needs to perform all activities,
from taking a breath to strenuous athletic activity. © Dreamstime
Good nutrition equates to receiving enough (but not too much) of the macronutrients (proteins, carbohydrates, fats, and water) and
micronutrients (vitamins and minerals) so that the body can stay healthy, grow properly, and work effectively. The phrase “you are
what you eat” refers to the fact that your body will respond to the food it receives, either good or bad. Processed, sugary, high-fat,
and excessively salted foods leave the body tired and unable to perform effectively. By contrast, eating fresh, natural whole foods
fuels the body by providing what it needs to produce energy, promote metabolic activity, prevent micronutrient deficiencies, ward
off chronic disease, and to promote a sense of overall health and well-being.

2.2.1 [Link]
 Table : Why Nutrition Is Important to Health

Necessary for tissue formation, cell reparation, and hormone and

Protein enzyme production. It is essential for building strong muscles and
a healthy immune system.
Provide a ready source of energy for the body and provide
Carbohydrates
structural constituents for the formation of cells.
Provides stored energy for the body, functions as structural
components of cells and also as signaling molecules for proper
Fat
cellular communication. It provides insulation to vital organs and
works to maintain body temperature.

Regulate body processes and promote normal body-system

Vitamins
functions.
Regulate body processes, are necessary for proper cellular
Minerals
function, and comprise body tissue.
Transports essential nutrients to all body parts, transports waste
Water products for disposal, and aids with body temperature
maintenance.

Undernutrition, Overnutrition, and Malnutrition

For many, the word “malnutrition” produces an image of a child in a third-world country with a bloated belly, and skinny arms and
legs. However, this image alone is not an accurate representation of the state of malnutrition. For example, someone who is 150
pounds overweight can also be malnourished. Malnutrition refers to one not receiving proper nutrition and does not distinguish
between the consequences of too many nutrients or the lack of nutrients, both of which impair overall health. Undernutrition is
characterized by a lack of nutrients and insufficient energy supply, whereas overnutrition is characterized by excessive nutrient and
energy intake. Overnutrition can result in obesity, a growing global health threat. Obesity is defined as a metabolic disorder that
leads to an overaccumulation of fat tissue.
Although not as prevalent in America as it is in developing countries, undernutrition is not uncommon and affects many
subpopulations, including the elderly, those with certain diseases, and those in poverty. Many people who live with diseases either
have no appetite or may not be able to digest food properly. Some medical causes of malnutrition include cancer, inflammatory
bowel syndrome, AIDS, Alzheimer’s disease, illnesses or conditions that cause chronic pain, psychiatric illnesses, such as anorexia
nervosa, or as a result of side effects from medications. Overnutrition is an epidemic in the United States and is known to be a risk
factor for many diseases, including Type 2 diabetes, cardiovascular disease, inflammatory disorders (such as rheumatoid arthritis),
and cancer.

Growth and Development

From birth to adulthood, nutrients fuel proper growth and function of all body cells, tissue, and systems. Without proper amounts of
nutrients, growth and development are stunted. Some nutrient deficiencies manifest right away, but sometimes the effects of
undernutrition aren’t seen until later in life. For example, if children do not consume proper amounts of calcium and vitamin D,
peak bone mass will be reduced compared to what it would be had adequate amounts of these nutrients been consumed. When
adults enter old age without adequate bone mass, they are more susceptible to osteoporosis, putting them at risk for bone fractures.
Therefore, it is vital to build bone strength through proper nutrition during youth because it cannot be done in later
[Link]. “Nutrients for the Growing Years.” Last reviewed August 13, 2003.
[Link]

2.2.2 [Link]
 Figure : Proper growth throughout the life stages depends upon proper
nutrition. © Dreamstime

The Healing Process

With all wounds, from a paper cut to major surgery, the body must heal itself. Healing is facilitated through proper
nutrition,MacKay, D., ND, and A. L. Miller, ND. “Nutritional Support for Wound Healing.” Alternative Medicine Review 8, no. 4
(2003): 359–77. while malnutrition inhibits and complicates this vital process. The following nutrients are important for proper
healing:

Figure : Healing, a critical function of a healthy body, is facilitated by adequate

nutrition.
Vitamin A. Helps to enable the epithelial tissue (the thin outer layer of the body and the lining that protects your organs) and
bone cells form.
Vitamin C. Helps form collagen, an important protein in many body tissues.
Protein. Facilitates tissue formation.
Fats. Play a key role in the formation and function of cell membranes.
Carbohydrates. Fuel cellular activity, supplying needed energy to support the inflammatory response that promotes healing.
Now that we have discussed the importance of proper nutrition for your body to perform normal tissue growth, repair, and
maintenance, we will discuss ways of achieving a healthy diet.

Key Takeaways
Nutrition promotes vitality and an overall sense of health and well-being by providing the body with energy and nutrients that
fuel growth, healing, and all body systems and functions. Good nutrition will also help to ward off the development of chronic
disease.
A person is malnourished by being either undernourished or overnourished. Malnutrition results when the body does not receive
the required amounts of calories, fats, proteins, carbohydrates, vitamins, and minerals necessary to keep the body and its
systems in good functioning order.

Discussion Starter
1. Describe what the phrase, “You are what you eat” means. Do you notice how you feel after eating certain types of foods? How
might this relate to your overall health?

2.2: A Healthy Philosophy toward Food is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

2.2.3 [Link]
2.3: What Is Nutritional Balance and Moderation?
Learning Objectives
Define the components of a healthful diet.

Achieving a Healthy Diet

Achieving a healthy diet is a matter of balancing the quality and quantity of food that is eaten. There are five key factors that make
up a healthful diet:
A diet must be adequate, by providing sufficient amounts of each essential nutrient, as well as fiber and calories.
A balanced diet results when you do not consume one nutrient at the expense of another, but rather get appropriate amounts of
all nutrients.
Calorie control is necessary so that the amount of energy you get from the nutrients you consume equals the amount of energy
you expend during your day’s activities.
Moderation means not eating to the extremes, neither too much nor too little.
Variety refers to consuming different foods from within each of the food groups on a regular basis.
A healthy diet is one that favors whole foods. As an alternative to modern processed foods, a healthy diet focuses on “real” fresh
whole foods that have been sustaining people throughout the millenniums. Whole foods supply the needed vitamins, minerals,
protein, carbohydrates, fats, and fiber that are essential to good health. Commercially prepared and fast foods are often lacking
nutrients and often contain inordinate amounts of sugar, salt, saturated and trans fats, all of which are associated with the
development of diseases such as atherosclerosis, heart disease, stroke, cancer, obesity, high cholesterol, diabetes, and other
illnesses. A balanced diet is a mix of food from the different food groups (vegetables, legumes, fruits, grains, protein foods, and
dairy).

Adequacy
An adequate diet is one that favors nutrient-dense foods. Nutrient-dense foods are defined as foods that contain many essential
nutrients per calorie. Nutrient-dense foods are the opposite of “empty-calorie” foods, such as sugary carbonated beverages, which
are also called “nutrient-poor.” Nutrient-dense foods include fruits and vegetables, lean meats, poultry, fish, low-fat dairy products,
and whole grains. Choosing more nutrient-dense foods will facilitate weight loss, while simultaneously providing all necessary
nutrients.

Tools for Change

Does your diet contain nutrient-dense foods? Record your eating habits for one week. Note the sugary, fatty, and calorie-heavy
foods you most often consume. Look at Table to decide what you can substitute those foods with.
Table : The Smart Choice: Nutrient-Dense Food Alternatives

2.3.1 [Link]
 Instead of… Replace with…

Sweetened fruit yogurt Plain fat-free yogurt with fresh fruit

Whole milk Low-fat or fat-free milk

Cheese Low-fat or reduced-fat cheese

Bacon or sausage Canadian bacon or lean ham

Sweetened cereals Minimally sweetened cereals with fresh fruit

Apple or berry pie Fresh apple or berries

Deep-fried French fries Oven-baked French fries or sweet potato baked fries

Fried vegetables Steamed or roasted vegetables

Sugary sweetened soft drinks Seltzer mixed with 100 percent fruit juice

Experiment with reducing amount of sugar and adding spices

Recipes that call for sugar
(cinnamon, nutmeg, etc…)
Source: US Department of Agriculture. “Food Groups.” [Link]/food-groups/.

Balance
Balance the foods in your diet. Achieving balance in your diet entails not consuming one nutrient at the expense of another. For
example, calcium is essential for healthy teeth and bones, but too much calcium will interfere with iron absorption. Most foods that
are good sources of iron are poor sources of calcium, so in order to get the necessary amounts of calcium and iron from your diet, a
proper balance between food choices is critical. Another example is that while sodium is a vital nutrient, an overabundance of it can
contribute to congestive heart failure and chronic kidney disease. Remember, everything must be consumed in the proper amounts.

Figure : With careful planning, a balanced diet providing optimal

nutrition can be achieved and maintained. © Shutterstock

Moderation
Eat in moderation. Moderation is crucial for optimal health and survival. Burgers, French fries, cake, and ice cream each night for
dinner will lead to health complications. But as part of an otherwise healthful diet and consumed only on a weekly basis, this
should not have too much of an impact on overall health. If this is done once per month, it will have even less of an impact upon
overall health. It’s important to remember that eating is, in part, about enjoyment and indulging with a spirit of moderation. This
fits within a healthy diet.

2.3.2 [Link]
Calorie Control
Monitor food portions. For optimum weight maintenance, it is important to ensure that energy consumed from foods meets the
energy expenditures required for body functions and activity. If not, the excess energy contributes to gradual, steady weight gain. In
order to lose weight, you need to ensure that more calories are burned than consumed. Likewise, in order to gain weight, calories
must be eaten in excess of what is expended daily. So what exactly is a Calorie anyway? Watch this YouTube Video called "What is
a calorie? - Emma Bryce"

Figure : The number of calories consumed should always match the

number of calories being expended by the body to maintain a healthy weight.© Networkgraphics

Variety
Variety involves eating different foods from all the food groups. Eating a varied diet helps to ensure that you receive all the
nutrients necessary for a healthy diet. One of the major drawbacks of a monotonous diet is the risk of consuming too much of some
nutrients and not enough of others. Trying new foods can also be a source of pleasure—you never know what foods you might like
until you try them.
Table : Food Choices for a Healthful Diet

2.3.3 [Link]
 Grain Vegetable Fruit Dairy Protein

Whole-grain products,
brown rice, quinoa,
all fluid milk (fat free,
barley, buckwheat, Dark green: broccoli,
low-fat, reduced-fat,
millet, wild rice, oats, collards, kale, romaine Meats: beef, ham, lamb,
apples, apricots, bananas whole milk, lactose-
rye berries, sorghum, lettuce, spinach, turnip pork, veal
free), fortified soy milk,
bulgur, kasha, farrow, greens, watercress
yogurt
wheat berries, corn,
amaranth, spelt, Teff

Berries: strawberries,
Red and orange: Acorn
blueberries, raspberries, Hard natural cheeses:
squash, butternut squash, Poultry: chicken, goose,
cherries, grapefruit, kiwi cheddar, mozzarella,
carrots, pumpkin, red turkey, duck
fruit, lemons, limes, Swiss, parmesan
peppers, sweet potatoes
mangoes

Beans and peas: Black

beans, black-eyed peas,
chickpeas, kidney beans, Melons: cantaloupe, Soft cheeses: ricotta,
Eggs
lentils, navy beans, pinto honey dew, watermelon cottage
beans, soybeans, split
peas, white beans

Starchy: Cassava, green

Other fruits: nectarines,
bananas, green peas,
oranges, peaches, pears, Beans and peas: (see
green lima beans,
papaya, pineapple, vegetable column)
plantains, potatoes, taro,
plums, prunes
water chestnuts

Other vegetables:
Asparagus, avocado, Nuts and seeds:
bean sprouts, beets, almonds, cashews,
Brussels sprouts, hazelnuts, peanuts,
cabbage, cauliflower, pecans, pistachios,
celery, eggplant, green pumpkin seeds, sesame
beans, green peppers, seeds, sunflower seeds,
mushrooms, okra, walnuts
onions, parsnips

Seafood: catfish, cod,

flounder, haddock,
halibut, herring,
mackerel, pollock, porgy,
salmon, sea bass,
snapper, swordfish, trout,
tuna
Shellfish: scallops,
muscles, crab, lobster

Source: Adapted from [Link]/food-groups/[Link].

2.3.4 [Link]
 Figure : Scientific evidence confirms that a diet full of fresh
whole foods reduces the risks for developing chronic disease and helps maintain a healthy weight. © Dreamstime

Video Link
Different Types of Grains: In this video, a registered dietitian discusses the benefits of eating whole
grains. [Link]

Developing a healthful diet can be rewarding, but be mindful that all of the principles presented must be followed to derive
maximal health benefits. For instance, introducing variety in your diet can still result in the consumption of too many high-calorie,
nutrient-poor foods and inadequate nutrient intake if you do not also employ moderation and calorie control. Using all of these
principles together will afford you lasting health benefits.

Figure : Widening your food palate will increase your intake of vital nutrients. © Dreamstime

Key Takeaways
A healthful diet is adequate in providing proper amounts of nutrient-dense foods, is balanced in relation to food types so that
one nutrient is not consumed at the expense of another, practices calorie control by supplying food energy to match energy
output, is moderate in unwanted constituents, and draws from a variety of nutritious foods.
Nutrient-dense foods contribute to daily nutritional requirements while limiting caloric intake, thus allowing people to either
lose weight safely or to maintain a healthy weight.

Discussion Starters
1. Discuss the principles of a healthy diet. How can you employ these principles in your diet, if you are not already?
2. Review the list of grains in Table 2.3. Pick one that you have not tried before. Make a dish using this grain. Discuss with your
classmates your experience eating this new food.

2.3: What Is Nutritional Balance and Moderation? is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by
LibreTexts.

2.3.5 [Link]
2.3.6 [Link]
2.4: National Goals for Nutrition and Health- Healthy People 2020
Learning Objectives
State the Healthy People 2020 nutrition- and weight-status goals.
List three related objectives for the Healthy People 2020 program.

The Healthy People 2020 program, launched in 2010, is a ten-year national program instituted by the US government with
objectives aimed toward improving the health of all Americans. Similar to the 2010 Dietary Guidelines, it has been established to
promote longer lives free of preventable disease, disability, injury, and premature death. With a revived intent on identifying,
measuring, tracking, and reducing health disparities through a “determinants of health approach,” Healthy People 2020 will strive
to create the social and physical environments that promote good health for all and to promote quality of life, healthy development,
and healthy behaviors across all life stages. This means that the understanding of what makes and keeps people healthy is
consistently refined. The determinants of health approach reflects the evidence from outside factors that greatly affect the health of
[Link] Department of Health and Human Services. “About Healthy People.” Last updated March 29, 2012.
[Link] It takes into consideration the circumstances in which people are born, live,
work, and age. It also reflects the conditions that shape their circumstances such as money, power, and resources at the local,
national, and global levels. Social determinants of health are primarily accountable for the lack of fair health opportunities and the
unjust differences in health status that exist within and between [Link] Health Organization. “Social Determinants of
Health.” © 2012. [Link]

Video : Preparing for the Next Decade

Preparing for the Next Decade: A 2020…

2020…

Preparing for the Next Decade: A 2020 Vision for Healthy People (click to see video)

Helping People Make Healthy Choices

It is not just ourselves, the food industry, and federal government that shape our choices of food and physical activity, but also our
sex, genetics, disabilities, income, religion, culture, education, lifestyle, age, and environment. All of these factors must be
addressed by organizations and individuals that seek to make changes in dietary habits. The socioeconomic model incorporates all
of these factors and is used by health-promoting organizations, such as the USDA and the HHS to determine multiple avenues
through which to promote healthy eating patterns, to increase levels of physical activity, and to reduce the risk of chronic disease
for all Americans.

2.4.1 [Link]
 Figure : The socioeconomic model helps organizations and the government to
plan and promote effective healthy-eating programs tailored to specific populations. © Networkgraphics
Lower economic prosperity influences diet specifically by lowering food quality, decreasing food choices, and decreasing access to
enough food. As a result of the recent financial crisis in America the number of people who struggle to have enough to eat is rising
and approaching fifty million. In response to these recent numbers, USDA Secretary Tom Vilsack said, “These numbers are a wake-
up call…for us to get very serious about food security and hunger, about nutrition and food safety in this country.”Amy Goldstein,
“Hunger a Growing Problem in America, USDA Reports,” Washington Post, 17 November 2009. [Link]/wp-
dyn...[Link].

Video : Determinants of Health

Determinants of Health Approach in Healthy People 2020 (click to see video)

Goals for Nutrition and Weight Status

While Healthy People 2020 has many goals and objectives, we are going to focus on the two goals for nutrition and weight status.
They are to promote health and reduce the risk of developing chronic diseases by encouraging Americans to consume healthful
diets and to achieve and maintain healthy body weights. Nutrition criteria are reflective of a solid scientific foundation for health
and weight management. Emphasis is on modifying individual behavior patterns and habits, and having policies and environments
that will support these behaviors in various settings, such as schools and local community-based organizations.

2.4.2 [Link]
 Figure : One of the ways that Healthy People 2020 strives to
promote good health and nutrition is by bringing together multiple agencies and groups dedicated to achieving the Healthy People
2020 nationwide objectives. © Shutterstock
Healthy People 2020 has defined their mission as:
Identify nationwide health improvement priorities
Increase public awareness and understanding of the determinants of health, disease, and disability, and the opportunities for
progress
Provide measurable objectives and goals that are applicable at the national, state, and local levels
Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best knowledge
Identify critical research, evaluation, and data-collection needs
Healthy People 2020 has set key recommendations as follows:
Consume a variety of nutrient-dense foods within and across the food groups, especially whole grains, fruits, vegetables, low-
fat or fat-free milk or milk products, and lean meats and other protein sources
Limit the intake of saturated fat and trans fats, cholesterol, added sugars, sodium (salt), and alcohol
Limit caloric intake to meet caloric needsUS Department of Health and Human Services. “Nutrition and Weight Status.”
[Link]. Last updated May 1, 2012. [Link]

Figure : Consuming nutrient-dense foods and limiting portion

sizes of food will contribute to weight management. Avoiding excessive amounts of anything allows room for many food types in
the diet. © Dreamstime

Tools for Change

If you wait many hours between meals, there is a good chance you will overeat. To refrain from overeating try consuming small
meals at frequent intervals throughout the day as opposed to two or three large meals. Eat until you are satisfied, not until you feel
“stuffed.” Eating slowly and savoring your food allows you to both enjoy what you eat and have time to realize that you are full
before you get overfull. Your stomach is about the size of your fist but it expands if you eat excessive amounts of food at one
sitting. Eating smaller meals will diminish the size of your appetite over time so you will feel satisfied with smaller amounts of
food.

2.4.3 [Link]
Benefits of Following the Healthy People 2020 Goals
Nutrition and weight status are important to children’s growth and development. In addition, healthy eating habits will decrease
risks for developing chronic health conditions such as obesity, malnutrition, anemia, cardiovascular disease, high blood pressure,
dyslipidemia (poor lipid profiles), Type 2 diabetes, osteoporosis, dental disease, constipation, diverticular disease, and certain types
of cancer.

Figure : Following the 2015 Dietary Guidelines will promote nutrition,

weight loss, and weight maintenance as well as the reduction of chronic disease. © Networkgraphics
Meeting the recommended intake for energy needs by adopting a balanced eating regimen as promoted by the USDA’s My Food
Plate tool will assist people in losing and maintaining weight and in improving overall health.

Objectives Related to the Healthy People 2020 Goals

Seven out of every ten deaths in the United States are caused by chronic diseases, such as heart disease, cancer, and diabetes, and
three-quarters of the country’s health spending goes toward the cost of treating these diseases. Helping people lose weight, maintain
a healthy weight, and prevent chronic disease by improving dietary habits requires providing education about food and nutrition,
assuring access to healthier food options, and promoting the desire and ability to become physically active. Some of the Healthy
People 2020 program’s related objectives are discussed below.
1. Improve health, fitness, and quality of life through daily physical activity. The Healthy People 2020 objectives for physical
activity are based on the 2008 Physical Activity Guidelines for Americans, and reflect the strong scientific evidence supporting
the benefits of physical activity. More than 80 percent of the current US population, from youth to adults, is not meeting these
guidelines. Healthy People 2020 highlights the way that one’s level of physical activity is affected by environmental factors
such as the availability of safe sidewalks, bike lanes, trails, and parks. It also highlights the legislative policies that improve
access to facilities that promote physical activity. Understanding that personal, social, economic, and environmental barriers to
physical activity all have a part in determining a population’s physical activity level, is an important part of being able to
provide interventions that foster physical activity. Consistent physical activity is necessary for preventing chronic disease,
improving bone health, decreasing body fat, and preventing an early death.

Video : Active versus Sedentary Lifestyles

2.4.4 [Link]
 An Introduction to Active vs. Sedentar…
Sedentar…

This video provides a short overview of leading an active life versus a sedentary life.

2. Increase the quality, availability, and effectiveness of educational and community-based programs designed to prevent
disease and injury, improve health, and enhance quality of life. Healthy eating is a learned behavior. By increasing the
number of community-based programs (schools, workplace, health-care facilities, local community groups) that offer guidance
for healthy eating and lifestyle choices, people of all ages will learn good eating habits and will gain access to good food
choices to help improve their diet and overall health.
3. Improve the development, health, safety, and well-being of adolescents and young adults. Adolescents (ten to nineteen
years of age) and young adults (twenty to twenty-four years of age) constitute 21 percent of the population of the United States.
The financial burdens of preventable health problems and associated long-term costs of chronic diseases in this demographic
group have the potential to be vast, and will be the result of attitudes and behaviors initiated during adolescence. For example,
the annual adult health-related financial burden of cigarette smoking, which usually starts by age eighteen, is $193
[Link], B. et al. “Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United
States, 2000–2004.” MMWR CDC Surveill Summ 57, no. 45 (November 14, 2008): 1226–8.
[Link]

Figure : Healthy children will lead to a healthy adult

population with less disease, lower healthcare costs, and increased longevity. © Shutterstock
4. Reduce the consumption of calories from SoFAS in the population aged two years and older. A diet high in SoFAS
contributes to excessive weight gain and poor health. Added sugars provide no nutritional value to foods. Excessive fat and
sugar intake promotes tooth decay, obesity, Type 2 diabetes, unhealthy cholesterol levels, and heart disease. Being overweight
increases susceptibility for developing high blood pressure, diabetes, cardiovascular diseases, and certain types of cancer. The
evidence is clear that many chronic diseases are linked to unhealthy dietary patterns. Excessive consumption of SoFAS, in
combination with the lack of plant-based foods, may contribute to higher rates of developing chronic diseases.
For more information on Healthy People 2020 and its related objectives for nutrition and weight status, please visit the website
[Link]

2.4.5 [Link]
Key Takeaways
Healthy People 2020 is a health initiative with a ten-year objective of helping Americans improve health and well-being, and to
live long, healthy lives. Among its many objectives are to promote health and reduce the risk of developing chronic diseases by
encouraging Americans to consume healthful diets and to achieve and maintain healthy body weights.
The goals of Healthy People 2020 are founded upon a determinants of health approach, which means they are reflective of the
circumstances in which people are born, live, and work, as well as the conditions that shape their circumstances such as money,
power, and resources at the local, national, and global levels. Diet patterns are influenced by genetics, environment, and cultural
values. All of these things must be considered to provide the optimal approach to improving the health of the American
population.
Decreasing caloric intake and increasing physical activity are important strategies in achieving the goals of the Healthy People
2020 program.

Discussion Starters
1. Think of fun ways to increase physical activity in your life. Think small but frequent and think about things you can incorporate
easily in your regular daily activities.
2. Review some of the Healthy People 2020 nutrition and physical activity program objectives. What objectives would you like to
see enacted in your community? Why is this important to you? [Link]

2.4: National Goals for Nutrition and Health- Healthy People 2020 is shared under a CC BY-NC-SA license and was authored, remixed, and/or
curated by LibreTexts.

2.4.6 [Link]
2.5: Recommendations for Optimal Health
Learning Objectives
Design a quality diet plan using MyPlate Daily Food Plan.
State recommendation(s) for fruit and vegetable consumption and list the potential benefits of this eating program.

For many years, the US government has been encouraging Americans to develop healthful dietary habits. In 1992 the food pyramid
was introduced, and in 2005 it was updated. This was the symbol of healthy eating patterns for all Americans. However, some felt it
was difficult to understand, so in 2011, the pyramid was replaced with Choose MyPlate.
The Choose MyPlate program uses a tailored approach to give people the needed information to help design a healthy diet. The
plate is divided according to the amount of food and nutrients you should consume for each meal. Each food group is identified
with a different color, showing the food variety that all plates must have. Aside from educating people about the type of food that is
best to support optimal health, the new food plan offers the advice that it is okay to enjoy food, just eat less of [Link] Department of
Agriculture. Accessed July 22, 2012. [Link]

Video : Introducing the New Food Icon: MyPlate

This video provides an introduction to the new MyPlate food guide.

Introducing the New Food Icon: MyPla…

MyPla…

Building a Healthy Plate: Choose Nutrient-Rich Foods

Planning a healthy diet using the MyPlate approach is not difficult. According to the icon, half of your plate should have fruits and
vegetables, one-quarter should have whole grains, and one-quarter should have protein. Dairy products should be low-fat or non-
fat. The ideal diet gives you the most nutrients within the fewest calories. This means choosing nutrient-rich foods.
Fill half of your plate with red, orange, and dark green vegetables and fruits, such as kale, collard greens, tomatoes, sweet potatoes,
broccoli, apples, oranges, grapes, bananas, blueberries, and strawberries in main and side dishes. Vary your choices to get the
benefit of as many different vegetables and fruits as you can. You may choose to drink fruit juice as a replacement for eating fruit.
(As long as the juice is 100 percent fruit juice and only half your fruit intake is replaced with juice, this is an acceptable exchange.)
For snacks, eat fruits, vegetables, or unsalted nuts.
Fill a quarter of your plate with whole grains such as 100 percent whole-grain cereals, breads, crackers, rice, and pasta. Half of
your daily grain intake should be whole grains. Read the ingredients list on food labels carefully to determine if a food is comprised
of whole grains.

2.5.1 [Link]
 Tools for Change

Consider the information in this video:

Buying Local - The Importance of local…

local…

Buying Local: The Importance of Locally Produced and Organically Grown Foods to Local Economy. (click to see video)

Identify which vegetables and fruits are in season and local to your area. By consuming in-season, local foods you cut down on
transportation costs (emission and financial) and you are likely to get fresher produce. You also support your local farms by
purchasing their produce.

Make sure at least half of your daily grain intake comes from whole-grain foods. © Shutterstock
Select a variety of protein foods to improve nutrient intake and promote health benefits. Each week, be sure to include a nice array
of protein sources in your diet, such as nuts, seeds, beans, legumes, poultry, soy, and seafood. The recommended consumption
amount for seafood for adults is two 4-ounce servings per week. When choosing meat, select lean cuts. Be conscious to prepare
meats using little or no added saturated fat, such as butter.

2.5.2 [Link]
 Remember to vary your selections of protein. Lentils contain good amounts of protein and make great meals. Try using lentils or
beans as a meat substitute each week. © Thinkstock
If you enjoy drinking milk or eating milk products, such as cheese and yogurt, choose low-fat or nonfat products. Low-fat and
nonfat products contain the same amount of calcium and other essential nutrients as whole-milk products, but with much less fat
and calories. Calcium, an important mineral for your body, is also available in lactose-free and fortified soy beverage and rice
beverage products. You can also get calcium in vegetables and other fortified foods and beverages.
Oils are essential for your diet as they contain valuable essential fatty acids, but the type you choose and the amount you consume
is important. Be sure the oil is plant-based rather than based on animal fat. You can also get oils from many types of fish, as well as
avocados, and unsalted nuts and seeds. Although oils are essential for health they do contain about 120 calories per tablespoon. It is
vital to balance oil consumption with total caloric intake. The Nutrition Facts label provides the information to help you make
healthful decisions.
In short, substituting vegetables and fruit in place of unhealthy foods is a good way to make a nutrient-poor diet healthy again.
Vegetables are full of nutrients and antioxidants that help promote good health and reduce the risk for developing chronic diseases
such as stroke, heart disease, high blood pressure, Type 2 diabetes, and certain types of cancer. Regularly eating fresh fruits and
vegetables will boost your overall health profile.

Discretionary Calories
When following a balanced, healthful diet with many nutrient-dense foods, you may consume enough of your daily nutrients before
you reach your daily calorie limit. The remaining calories are discretionary (to be used according to your best judgment). To find
out your discretionary calorie allowance, add up all the calories you consumed to achieve the recommended nutrient intakes and
then subtract this number from your recommended daily caloric allowance. For example, someone who has a recommended 2,000-
calorie per day diet may eat enough nutrient-dense foods to meet requirements after consuming only 1,814 calories. The remaining
186 calories are discretionary. These calories may be obtained from eating an additional piece of fruit, adding another teaspoon of
olive oil on a salad or butter on a piece of bread, adding sugar or honey to cereal, or consuming an alcoholic [Link]
Department of Agriculture. “MyPyramid Education Framework.” Accessed July 22, 2012. [Link]
The amount of discretionary calories increases with physical activity level and decreases with age. For most physically active
adults, the discretionary calorie allowance is, at most, 15 percent of the recommended caloric intake. By consuming nutrient-dense
foods, you afford yourself a discretionary calorie allowance.
Table : Sample Menu Plan Containing 2,000 Calories

2.5.3 [Link]
 Meal Calories Total Meal/Snack Calories

Breakfast

1 scrambled egg 92

with sliced mushrooms and spinach 7

½ whole-wheat muffin 67

1 tsp. margarine-like spread 15

1 orange 65

8 oz. low-sodium tomato juice 53 299

Snack

6 oz. fat-free flavored yogurt 100

with ½ c. raspberries 32 132

Lunch

1 sandwich on pumpernickel bread 160

with smoked turkey deli meat, 30

4 slices tomato 14

2 lettuce leaves 3

1 tsp. mustard 3

1 oz. baked potato chips 110

½ c. blueberries, with 1 tsp. sugar 57

8 oz. fat-free milk 90 467

Snack

1 banana 105

7 reduced-fat high-fiber crackers 120 225

Dinner

1 c. Greek salad (tomatoes, cucumbers,

150
feta)

with 5 Greek olives, 45

with 1.5 tsp. olive oil 60

3 oz. grilled chicken breast 150

½ c. steamed asparagus 20

with 1 tsp. olive oil, 40

with 1 tsp. sesame seeds 18

½ c. cooked wild rice 83

with ½ c. chopped kale 18

2.5.4 [Link]
 Meal Calories Total Meal/Snack Calories

1 whole-wheat dinner roll 4

with 1 tsp. almond butter 33 691

(Total calories from all meals and snacks = 1,814)

Discretionary calorie allowance: 186

Healthy Eating Index

To assess whether the American diet is conforming to the 2010 Dietary Guidelines, the Center for Nutrition Policy and Promotion
(CNPP), a division of the USDA, uses a standardized tool called the Healthy Eating Index (HEI).US Department of Agriculture.
“Healthy Eating Index.” Last modified March 14, 2012. [Link]/[Link]. The first HEI was developed
in 1995 and revised in 2006. This tool is a simple scoring system of dietary components. The data for scoring diets is taken from
national surveys of particular population subgroups, such as children from low-income families or Americans over the age of sixty-
five. Diets are broken down into several food categories including milk, whole fruits, dark green and orange vegetables, whole
grains, and saturated fat, and then a score is given based on the amount consumed. For example, a score of ten is given if a 2,000-
kilocalorie diet includes greater than 2.6 cups of milk per day. If less than 10 percent of total calories in a diet are from saturated
fat, a score of eight is given. All of the scores are added up from the different food categories and the diets are given a HEI score.
Using this standardized diet-assessment tool at different times, every ten years for instance, the CNPP can determine if the eating
habits of certain groups of the American population are getting better or worse. The HEI tool provides the federal government with
information to make policy changes to better the diets of American people. For more information on the HEI, visit this website:
[Link]/[Link].

Key Takeaways
The Food Pyramid has been replaced by MyPlate, a system that was designed to be easier to implement. The new MyPlate
encourages all plates to be filled with fruits and vegetables (50 percent), protein (25 percent), and grains (25 percent). Half of
daily grain intake should be from whole-grain sources. Dairy choices should be switched to low-fat or non-fat sources.
A diet rich in fresh fruits and vegetables will help you lose and/or maintain weight, will lower your risk for stroke, heart disease,
high blood pressure, Type 2 diabetes, and certain types of cancer, and will boost your overall health profile.
By choosing nutrient-dense foods, you may have discretionary calories to “spend” at the end of the day.

Discussion Starter
1. As you analyze the new MyPlate, how do your regular dietary habits compare to this new format? What changes, if any, will
you have to make to your breakfast? Lunch? Dinner?

2.5: Recommendations for Optimal Health is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

2.5.5 [Link]
2.6: Understanding Dietary Reference Intakes (DRI)
Learning Objectives
Use the Dietary Reference Intakes to determine daily nutrient recommendations.

Dietary Reference Intakes (DRI) are the recommendation levels for specific nutrients and consist of a number of different types of
recommendations. This DRI system is used in both the United States and Canada.

Dietary Reference Intakes: A Brief Overview

The most recent recommendations from the Food and Nutrition Board are the “Dietary Reference Intakes” (DRI). The DRI include
4 sets of standards:
Recommended Dietary Allowances (RDA): average daily level of intake sufficient to meet the nutrient requirements of nearly
all (97%-98%), healthy people.
Adequate Intakes (AI): established when evidence is insufficient to develop an RDA and is set at a level assumed to ensure
nutritional adequacy.
Tolerable Upper Intake Levels (UL): maximum daily intake unlikely to cause adverse health effects.
Estimated Average Requirements (EARs): expected to satisfy the needs of 50% of the people in that age group based on a
review of the scientific literature.
The DRIs are not minimum or maximum nutritional requirements and are not intended to fit everybody. They are to be used as
guides only for the majority of the healthy population. [Link]

Figure : The DRIs are inclusive of all four reference

values. © Networkgraphics
DRIs are important not only to help the average person determine whether their intake of a particular nutrient is adequate, they are
also used by health-care professionals and policy makers to determine nutritional recommendations for special groups of people
who may need help reaching nutritional goals. This includes people who are participating in programs such as the Special
Supplemental Food Program for Women, Infants, and Children. The DRI is not appropriate for people who are ill or malnourished,
even if they were healthy previously.

Determining Dietary Reference Intakes

Each DRI value is derived in a different way. See below for an explanation of how each is determined:
1. Estimated Average Requirements. The EAR for a nutrient is determined by a committee of nutrition experts who review the
scientific literature to determine a value that meets the requirements of 50 percent of people in their target group within a given
life stage and for a particular sex. The requirements of half of the group will fall below the EAR and the other half will be above
it. It is important to note that, for each nutrient, a specific bodily function is chosen as the criterion on which to base the EAR.
For example, the EAR for calcium is set using a criterion of maximizing bone health. Thus, the EAR for calcium is set at a
point that will meet the needs, with respect to bone health, of half of the population. EAR values become the scientific
foundation upon which RDA values are set.
2. Recommended Daily Allowances. Once the EAR of a nutrient has been established, the RDA can be mathematically
determined. While the EAR is set at a point that meets the needs of half the population, RDA values are set to meet the needs of
the vast majority (97 to 98 percent) of the target healthy population. It is important to note that RDAs are not the same thing as
individual nutritional requirements. The actual nutrient needs of a given individual will be different than the RDA. However,

2.6.1 [Link]
 since we know that 97 to 98 percent of the population’s needs are met by the RDA, we can assume that if a person is consuming
the RDA of a given nutrient, they are most likely meeting their nutritional need for that nutrient. The important thing to
remember is that the RDA is meant as a recommendation and meeting the RDA means it is very likely that you are meeting
your actual requirement for that nutrient.

Understanding the Difference

There is a distinct difference between a requirement and a recommendation. For instance, the DRI for vitamin D is a recommended
600 international units each day. However, in order to find out your true personal requirements for vitamin D, a blood test is
necessary. The blood test will provide an accurate reading from which a medical professional can gauge your required daily
vitamin D amounts. This may be considerably more or less than the DRI, depending on what your level actually is.
1. Adequate Intake. AIs are created for nutrients when there is insufficient consistent scientific evidence to set an EAR for the
entire population. As with RDAs, AIs can be used as nutrient-intake goals for a given nutrient. For example, there has not been
sufficient scientific research into the particular nutritional requirements for infants. Consequently, all of the DRI values for
infants are AIs derived from nutrient values in human breast milk. For older babies and children, AI values are derived from
human milk coupled with data on adults. The AI is meant for a healthy target group and is not meant to be sufficient for certain
at-risk groups, such as premature infants.
2. Tolerable Upper Intake Levels. The UL was established to help distinguish healthful and harmful nutrient intakes. Developed
in part as a response to the growing usage of dietary supplements, ULs indicate the highest level of continuous intake of a
particular nutrient that may be taken without causing health problems. When a nutrient does not have any known issue if taken
in excessive doses, it is not assigned a UL. However, even when a nutrient does not have a UL it is not necessarily safe to
consume in large amounts.

Figure : DRI Graph. This graph illustrates the risks of

nutrient inadequacy and nutrient excess as we move from a low intake of a nutrient to a high intake. Starting on the left side of the
graph, you can see that when you have a very low intake of a nutrient, your risk of nutrient deficiency is high. As your nutrient
intake increases, the chances that you will be deficient in that nutrient decrease. The point at which 50 percent of the population
meets their nutrient need is the EAR, and the point at which 97 to 98 percent of the population meets their needs is the RDA. The
UL is the highest level at which you can consume a nutrient without it being too much—as nutrient intake increases beyond the
UL, the risk of health problems resulting from that nutrient increases. Source: Institute of Medicine. © 2012 National Academy of
Sciences. All Rights Reserved. [Link].
3. Acceptable Macronutrient Distribution Ranges. The Acceptable Macronutrient Distribution Range (AMDR) is the calculated
range of how much energy from carbohydrates, fats, and protein is recommended for a healthy diet. People who do not reach
the AMDRs for their target group increase their risk of developing health complications.
Table 2.7: AMDR Values for Adults

2.6.2 [Link]
 Nutrient Value (percentage of Calories)

Fat 20.0–35.0

Carbohydrate 45.0–65.0

Protein 10.0–35.0

Polyunsaturated fatty acids 5.0–10.0

Linolenic acid 0.6–1.2

Source: Food and Nutrition Board of the Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty
Acids, Cholesterol, Protein, and Amino Acids. (Washington, DC: National Academies Press, 2002).

Tips for Using the Dietary Reference Intakes to Plan Your Diet

You can use the DRIs to help assess and plan your diet. Keep in mind when evaluating your nutritional intake that the values
established have been devised with an ample safety margin and should be used as guidance for optimal intakes. Also, the
values are meant to assess and plan average intake over time; that is, you don’t need to meet these recommendations every
single day—meeting them on average over several days is sufficient.

Key Takeaways
Nutrient-intake recommendations set for healthy people living in the United States and Canada are known as Dietary Reference
Intakes.
The DRIs includes the AI, EAR, RDA, and UL for micronutrients and the AMDR ranges for energy-yielding macronutrients.
The DRI provide a set of standards for researchers and government policy-makers, and specifies nutrient consumption
guidelines for individuals.

Discussion Starter
1. Why do you think it is important for the government to set the DRI standards? How will you use this information for your
personal dietary choices?

2.6: Understanding Dietary Reference Intakes (DRI) is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by
LibreTexts.

2.6.3 [Link]
2.7: Understanding the Bigger Picture of Dietary Guidelines
Learning Objectives
Describe the major themes of the 2015-2020 Dietary Guidelines for Americans.

The first US dietary recommendations were set by the National Academy of Sciences in 1941. The recommended dietary
allowances (RDA) were first established out of concern that America’s overseas World War II troops were not consuming enough
daily nutrients to maintain good health. The first Food and Nutrition Board was created in 1941, and in the same year set
recommendations for the adequate intakes of caloric energy and eight essential nutrients. These were disseminated to officials
responsible for food relief for armed forces and civilians supporting the war effort. Since 1980, the dietary guidelines have been
reevaluated and updated every five years by the advisory committees of the US Department of Agriculture (USDA) and the US
Department of Health and Human Services (HHS). The guidelines are continually revised to keep up with new scientific evidence-
based conclusions on the importance of nutritional adequacy and physical activity to overall health. While dietary
recommendations set prior to 1980 focused only on preventing nutrient inadequacy, the current dietary guidelines have the
additional goals of promoting health, reducing chronic disease, and decreasing the prevalence of overweight and obesity.

Figure : Dietary guidelines help people to stay on a healthful track by drawing

attention to the overall scope of their diet and lifestyle. © Dreamstime

Why Are Guidelines Needed?

Instituting nation-wide standard policies provides consistency across organizations and allows health-care workers, nutrition
educators, school boards, and elder-care facilities to improve nutrition and subsequently the health of their respective populations.
The 2015–2020 Dietary Guidelines is designed to help Americans eat a healthier diet. Intended for policymakers and health
professionals, the 2015 edition of the Dietary Guidelines outlines how people can improve their overall eating patterns — the
complete combination of foods and drinks in their diet. The free 2015 edition offers overarching themes about what constitutes a
healthy diet, how to shift behaviors to make it possible to follow a healthful diet and a number of Key Recommendations with
specific nutritional targets and dietary limits

Figure : The major theme of the 20105 Dietary Guidelines for Americans is an
adequate diet combined with proper exercise. © Dreamstime

2.7.1 [Link]
Major Themes of the 2015 Dietary Guidelines
The 2015 Dietary Guidelines consists of five major action steps for the American public to improve their eating habits. It also
includes several key recommendations. These five steps are as follows:
1. Follow a healthy eating pattern across the lifespan.
2. Focus on variety, nutrient density, and amount.
3. Limit calories from added sugars and saturated fats and reduce sodium intake.
4. Shift to healthier food and beverage choices.
5. Support healthy eating patterns for all.
We will discuss the highlights of each chapter of the 2015 Dietary Guidelines; however, if you are interested in reading more, visit
the USDA website, [Link]
How should you develop a healthy eating plan to best achieve your goals of losing weight, gaining weight, or maintaining weight?
We will start with some basics and move on to healthy eating patterns. To provide further guidance, several key recommendations
are provided. These should be applied in their entirety because of their interconnectedness.
Consume a healthy eating pattern that accounts for all foods and beverages within an appropriate calorie level.
A health heating pattern includes:
A variety of vegetables from all of the subgroups - dark green, red and orange, legumes (beans and peas), starchy,
and other
Fruits, especially whole fruits
Grains, at least half of which are whole grains
Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages
A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), and nuts,
seeds, and soy products
Oils
The following components of the diet should be limited in order to achieve a healthy eating pattern:
Consume less than 10 percent of calories per day from added sugars
Consume less than 10 percent of calories per day from saturated fats
Consume less than 2,300 milligrams (mg) per day of sodium
If alcohol is consumed, it should be consumed in moderation - up to one drink per day for women and up to two
drinks per day for men - and only by adults of legal drinking age.
Finally, all Americans regardless of age should meet the Physical Activity Guidelines for Americans.

Foods and Food Components to Reduce

High consumptions of certain foods, such as those high in saturated or trans fat, sodium, added sugars, and refined grains may
contribute to the increased incidence of chronic disease. Additionally, excessive consumption of these foods replaces the intake of
more nutrient-dense foods.
Table : A Little Less of These, Please

2.7.2 [Link]
 Dietary Constituent Health Implications Recommendations

Excess sodium High blood pressure Limit intake to 2,300 mg daily

Limit intake to < 10 percent of total

Too much saturated fat Cardiovascular disease
calories

Trans fats Cardiovascular disease Minimal, if any consumption

Excess cholesterol Atherosclerosis Limit intake to below 300 mg daily

SoFAS (solid fats and added sugars) Obesity, Type 2 diabetes Avoid if possible

Impaired liver function, impaired motor No more than one drink per day for women;
Too much alcohol
function No more than two drinks per day for men

The average person consumes 3,400 milligrams of sodium per day, mostly in the form of table salt. The 2010 Dietary Guidelines
recommend that Americans reduce their daily sodium intake to less than 2,300 milligrams. If you are over the age of fifty-one, are
African American, or have cardiovascular risk factors, such as high blood pressure or diabetes, sodium intake should be reduced
even further to 1,500 milligrams. The Dietary Guidelines also recommend that less than 10 percent of calories come from saturated
fat, and that fat calories should be obtained by eating foods high in unsaturated fatty acids. Cholesterol intake should be decreased
to below 300 milligrams per day and trans fatty acid consumption kept to a bare minimum. The Dietary Guidelines stresses the
importance of limiting the consumption of foods with refined grains and added sugars, and introduce the new term, SoFAS, which
is an acronym for solid fats and added sugars, both of which are to be avoided in a healthy diet [Link], J. and K. Zeratsky.
“Dietary Guidelines Connect SoFAS and Weight Gain.” Mayo Clinic, Nutrition-Wise (blog). August 25, 2010.
[Link]/health/die...elines/MY01417. Moreover, if alcohol is consumed, it should be consumed only in moderation,
which for women it is not more than one drink per day and for men is not more than two drinks per day. The macronutrients
protein, carbohydrates, and fats contribute considerably to total caloric intake. The IOM has made recommendations for different
age groups on the percentage of total calories that should be obtained from each macronutrient class (Table ).
Table : Recommendations for Macronutrient Intake As Percentage of Total Calories

Age Group Protein (%) Carbohydrates (%) Fat (%)

Children (1–3) 5–20 45–65 30–40

Children and Adolescents (4–

10–30 45–65 25–35
18)

Adults (>19) 10–35 45–65 20–35

Source: 2010 Dietary Guidelines.

Foods and Nutrients to Increase

The typical American diet lacks sufficient amounts of vegetables, fruits, whole grains, and high-calcium foods, causing concern for
deficiencies in certain nutrients important for maintaining health. The 2010 Dietary Guidelines provide the following suggestions
on food choices to achieve a healthier diet:
1. Eat a variety of vegetables, especially dark green, red, and orange vegetables.
2. Choose at least half of your grains consumed from whole-grain foods.
3. For dairy products, eat the low-fat versions.
4. Don’t get your protein only from red meats; choose instead seafood, poultry, eggs, beans, peas, nuts, seeds, and soy products.
5. Replace butter with oils.
6. Choose foods dense in the nutrients potassium, calcium, and vitamin D.
7. Increase intake of dietary fiber.

2.7.3 [Link]
Building Healthy Eating Patterns
The 2010 Dietary Guidelines recommend that people make an effort to reduce their caloric consumption, reduce the intake of
nutrient-poor foods, and increase the intake of nutrient-dense foods. To accomplish these tasks it is necessary to incorporate
moderation and variety. The goal is not only choosing specific foods for your diet, but also the development of a healthy eating
pattern. Several studies provide good evidence that certain dietary patterns increase overall health and decrease the risk of chronic
disease. The Dietary Approaches to Stop Hypertension trial, or DASH, reports that men and women who consumed more than eight
servings per day of fruits and vegetables had lower blood pressures than a control group that consumed under four servings per day
of fruits and [Link], F.M, et al., “Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to
Stop Hypertension (DASH) Diet.” N Engl J Med. 344, no. 1 (January 2001): 3–10.
[Link] Other studies investigating the benefits of the DASH diet have
also found it to be protective against cardiovascular disease and decrease overall mortality. Another well-known diet is the
Mediterranean diet. In general, the Mediterranean diet is described as one that emphasizes fruits, vegetables, whole grains, and
nuts, and olive oil as a replacement for butter. Few meats and high-fat dairy products are eaten. Observational studies have linked
the Mediterranean diet to reduced cardiovascular disease and decreased mortality. Vegetarian diets, which emphasize many of the
same foods as the DASH and Mediterranean diets have also been linked to a decrease in incidences of some chronic diseases.

Figure : Fresh vegetables and olive oil are examples of foods

emphasized in the DASH and Mediterranean diets. © Thinkstock

Key Takeaways
US dietary guidelines are based on evolving scientific evidence and are updated every five years. The goals of the 2015-2020
Dietary Guidelines are to prevent nutrient inadequacy, promote health, reduce chronic disease, and decrease the prevalence of
overweight and obesity.
To have a healthy eating pattern, reduce the intake of sodium, saturated and trans fats, cholesterol, added sugars, and refined
grains. Increase the consumption of fruits, vegetables, low-fat dairy products, dietary fiber, and oils.
Healthy eating patterns prevent chronic disease and provide nutrient adequacy.

Discussion Starter
1. Discuss with your classmates suggestions from the 2015-2020 Dietary Guidelines that you should incorporate into your diet.
How can you align your personal dietary goals with these recommendations?

2.7: Understanding the Bigger Picture of Dietary Guidelines is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated
by LibreTexts.

2.7.4 [Link]
2.8: Discovering Nutrition Facts
Learning Objectives
Use the Nutrition Facts panel to discover the nutritional information of food.

The Labels on Your Food

Understanding the significance of dietary guidelines and how to use DRIs in planning your nutrient intakes can make you better
equipped to select the right foods the next time you go to the supermarket.
In the United States, the Nutrition Labeling and Education Act passed in 1990 and came into effect in 1994. In Canada, mandatory
labeling came into effect in 2005. As a result, all packaged foods sold in the United States and Canada must have nutrition labels
that accurately reflect the contents of the food products. There are several mandated nutrients and some optional ones that
manufacturers or packagers include. Table lists the mandatory and optional inclusions.
Table : Mandatory and Optional Inclusions on Nutrition Labels
Mandatory Inclusion Optional Inclusion

Total Calories Calories from saturated fats

Calories from fat Polyunsaturated fat

Total fat Monounsaturated fat

Saturated fat Potassium

Cholesterol Soluble fiber

Total carbohydrates Sugar alcohol

Dietary fiber Other carbohydrates

Sugars Percent of vitamin A present as beta-carotene

Vitamins A and C Other essential vitamins and minerals

Calcium

Iron

Source: US Food and Drug Administration. “Food Labeling Guide.” Last updated February 10, 2012. [Link]

There are other types of information that are required by law to appear somewhere on the consumer packaging. They include:
Name and address of the manufacturer, packager, or distributor
Statement of identity, what the product actually is
Net contents of the package: weight, volume, measure, or numerical count
Ingredients, listed in descending order by weight
Nutrient information of serving size and daily values (US Food and Drug Administration. “Food Labeling & Nutrition”)
The Nutrition Facts panel provides a wealth of information about the nutritional content of the product. The information also allows
shoppers to compare products. Because the serving sizes are included on the label, you can see how much of each nutrient is in
each serving to make the comparisons. Knowing how to read the label is important because of the way some foods are presented.
For example, a bag of peanuts at the grocery store may seem like a healthy snack to eat on the way to class. But have a look at that
label. Does it contain one serving, or multiple servings? Unless you are buying the individual serving packages, chances are the bag
you picked up is at least eight servings, if not more.
According to the 2010 health and diet survey released by the FDA, 54 percent of first-time buyers of a product will check the food
label and will use this information to evaluate fat, calorie, vitamin, and sodium [Link] Food and Drug Administration. “Survey

2.8.1 [Link]
Shows Gain in Food-Label Use, Health/Diet Awareness.” March 2, 2010. [Link]/ForConsumers/Cons...abelHighlights. The
survey also notes that more Americans are using food labels and are showing an increased awareness of the connection between
diet and health. Having reliable food labels is a top priority of the FDA, which has a new initiative to prepare guidelines for the
food industry to construct “front of package” labeling that will make it even easier for Americans to choose healthy foods. Stay
tuned for the newest on food labeling by visiting the FDA website: [Link]

Interactive Link: The Food Label and You.

The FDA has prepared an Interactive Food Label that is packed with helpful information.
[Link]

Reading the Label

The first part of the Nutrition Facts panel gives you information on the serving size and how many servings are in the container. For
example, a label on a box of crackers might tell you that twenty crackers equals one serving and that the whole box contains 10
servings. All other values listed thereafter, from the calories to the dietary fiber, are based on this one serving. On the panel, the
serving size is followed by the number of calories and then a list of selected nutrients. You will also see “Percent Daily Value” on
the far right-hand side. This helps you determine if the food is a good source of a particular nutrient or not. The Daily Value (DV)
represents the recommended amount of a given nutrient based on the RDI of that nutrient in a 2,000-kilocalorie diet. The
percentage of Daily Value (percent DV) represents the proportion of the total daily recommended amount that you will get from
one serving of the food. For example, in the food label in Figure , the percent DV of calcium for one serving of macaroni-and-
cheese is 20 percent, which means that one serving of macaroni and cheese provides 20 percent of the daily recommended calcium
intake. Since the DV for calcium is 1,000 milligrams, the food producer determined the percent DV for calcium by taking the
calcium content in milligrams in each serving, and dividing it by 1,000 milligrams, and then multiplying it by 100 to get it into
percentage format. Whether you consume 2,000 calories per day or not you can still use the percent DV as a target reference.

Figure : Determining Your Nutrient Allowances per

Day. Pictured here is a sample label for macaroni and cheese. Source: FDA. “How to Understand and Use the Nutrition Facts
Panel.” Last updated February 15, 2012. [Link]/food/labelingnutr...[Link]#dvs
Generally, a percent DV of 5 is considered low and a percent DV of 20 is considered high. This means, as a general rule, for fat,
saturated fat, trans fat, cholesterol, or sodium, look for foods with a low percent DV. Alternatively, when concentrating on essential
mineral or vitamin intake, look for a high percent DV. To figure out your fat allowance remaining for the day after consuming one

2.8.2 [Link]
serving of macaroni-and-cheese, look at the percent DV for fat, which is 18 percent, and subtract it from 100 percent. To know this
amount in grams of fat, read the footnote of the food label to find that the recommended maximum amount of fat grams to consume
per day for a 2,000 kilocalories per day diet is 65 grams. Eighteen percent of sixty-five equals about 12 grams. This means that 53
grams of fat are remaining in your fat allowance. Remember, to have a healthy diet the recommendation is to eat less than this
amount of fat grams per day, especially if you want to lose weight.
Table : DVs Based on a Caloric Intake of 2,000 Calories (For Adults and Children Four or More Years of Age)

2.8.3 [Link]
Food Component DV

Total fat 65 g

Saturated fat 20 g

Cholesterol 300 mg

Sodium 2,400 mg

Potassium 3,500 mg

Total carbohydrate 300 g

Dietary fiber 25 g

Protein 50 g

Vitamin A 5,000 IU

Vitamin C 60 mg

Calcium 1,000 mg

Iron 18 mg

Vitamin D 400 IU

Vitamin E 30 IU

Vitamin K 80 micrograms µg

Thiamin 1.5 mg

Riboflavin 1.7 mg

Niacin 20 mg

Vitamin B6 2 mg

Folate 400 µg

Vitamin B12 6 µg

Biotin 300 µg

Pantothenic acid 10 mg

Phosphorus 1,000 mg

Iodine 150 µg

Magnesium 400 mg

Zinc 15 mg

Selenium 70 µg

Copper 2 mg

Manganese 2 mg

Chromium 120 µg

Molybdenum 75 µg

Chloride 3,400 mg

2.8.4 [Link]
 Food Component DV

Source: FDA, [Link]/Food/GuidanceComp.../[Link].

Of course, this is a lot of information to put on a label and some products are too small to accommodate it all. In the case of small
packages, such as small containers of yogurt, candy, or fruit bars, permission has been granted to use an abbreviated version of the
Nutrition Facts panel. To learn additional details about all of the information contained within the Nutrition Facts panel, see the
following website: [Link]/Food/ResourcesFor.../[Link]

Video Link: How to Read Food Labels.

Pay attention to the fine print when grocery shopping. [Link]

[Link]

Claims on Labels
In addition to mandating nutrients and ingredients that must appear on food labels, any nutrient-content claims must meet certain
requirements. For example, a manufacturer cannot claim that a food is fat-free or low-fat if it is not, in reality, fat-free or low-fat.
Low-fat indicates that the product has three or fewer grams of fat; low salt indicates there are fewer than 140 milligrams of sodium,
and low-cholesterol indicates there are fewer than 20 milligrams of cholesterol and two grams of saturated fat. See Table for
some [Link] Food and Drug Administration. “Additional Requirements for Nutrient Content Claims.” Appendix B in Food
Labeling Guide (October 2009).
Table : Common Label Terms Defined

Term Explanation

Fewer than a set amount of grams of fat for that particular cut of
Lean
meat

High Contains more than 20% of the nutrient’s DV

Good source Contains 10 to 19% of nutrient’s DV

Contains ⅓ fewer calories or 50% less fat; if more than half of

Light/lite calories come from fat, then fat content must be reduced by 50%
or more

Organic Contains 95% organic ingredients

Source: US Food and Drug Administration. “Food Labeling Guide.” Last updated February 10, 2012. [Link]

Health Claims
Often we hear news of a particular nutrient or food product that contributes to our health or may prevent disease. A health claim is a
statement that links a particular food with a reduced risk of developing disease. As such, health claims such as “reduces heart
disease,” must be evaluated by the FDA before it may appear on packaging. Prior to the passage of the NLEA products that made
such claims were categorized as drugs and not food. All health claims must be substantiated by scientific evidence in order for it to
be approved and put on a food label. To avoid having companies making false claims, laws also regulate how health claims are
presented on food packaging. In addition to the claim being backed up by scientific evidence, it may never claim to cure or treat the
disease. For a detailed list of approved health claims, visit: [Link]
claims-meet-significant-scientific-agreement-ssa-standard

Qualified Health Claims

While health claims must be backed up by hard scientific evidence, qualified health claims have supportive evidence, which is not
as definitive as with health claims. The evidence may suggest that the food or nutrient is beneficial. Wording for this type of claim
may look like this: “Supportive but not conclusive research shows that consumption of EPA and DHA omega-3 fatty acids may

2.8.5 [Link]
reduce the risk of coronary artery disease. One serving of [name of food] provides [X] grams of EPA and DHA omega-3 fatty acids.
[See nutrition information for total fat, saturated fat, and cholesterol content.]US Food and Drug Administration. “FDA Announces
Qualified Health Claims for Omega-3 Fatty Acids.”

Structure/Function Claims
Some companies claim that certain foods and nutrients have benefits for health even though no scientific evidence exists. In these
cases, food labels are permitted to claim that you may benefit from the food because it may boost your immune system, for
example. There may not be claims of diagnosis, cures, treatment, or disease prevention, and there must be a disclaimer that the
FDA has not evaluated the [Link] Food and Drug Administration. “Claims That Can Be Made for Conventional Foods and
Dietary Supplements.”

Allergy Warnings
Food manufacturers are required by the FDA to list on their packages if the product contains any of the eight most common
ingredients that cause food allergies. These eight common allergens are as follows: milk, eggs, peanuts, tree nuts, fish, shellfish,
soy, and wheat. (More information on these allergens will be discussed elseshere). The FDA does not require warnings that cross
contamination may occur during packaging, however most manufacturers include this advisory as a courtesy. For instance, you
may notice a label that states, “This product is manufactured in a factory that also processes peanuts.” If you have food allergies, it
is best to avoid products that may have been contaminated with the allergen.

Key Takeaways
The Nutrition Labeling and Education Act made it a law that foods sold in the United States have a food label that provides the
accurate contents of nutrients within them. Canada has a similar law.
A Nutrition Facts panel gives information on the amount of servings per container, the amount of calories per serving, and the
amounts of certain nutrients.
The percent DV is the percentage of the amount of the nutrient in the food in relationship to its recommended intake. It is a
guide to help you determine if a food is a good or poor source of nutrients.
To keep companies from making false claims, the FDA provides regulation for food manufacturers in putting labels on
packages that promote health. Allergens must also be listed on food labels. Sometimes cross contamination does occur during
packaging. Most food manufacturers voluntarily list this information. If you have a food allergy, it is best to avoid any product
that has even had the possibility of coming in contact with a known allergen.

Discussion Starter
1. Recall the food you buy from the supermarket on a regular basis. How many of the food products you purchase regularly are
nutrient-dense? How many are nutrient-poor? What foods can you substitute in place of the nutrient-poor food choices?

2.8: Discovering Nutrition Facts is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

2.8.6 [Link]
2.9: Building Healthy Eating Patterns
Helping People Make Healthy Choices
It is not just ourselves, the food industry, and federal government that shape our choices of food and physical activity, but also our
sex, genetics, disabilities, income, religion, culture, education, lifestyle, age, and environment. All of these factors must be
addressed by organizations and individuals that seek to make changes in dietary habits. The socioeconomic model incorporates all
of these factors and is used by health-promoting organizations, such as the USDA and the HHS to determine multiple avenues
through which to promote healthy eating patterns, to increase levels of physical activity, and to reduce the risk of chronic disease
for all Americans. Lower economic prosperity influences diet specifically by lowering food quality, decreasing food choices, and
decreasing access to enough food. The USDA reports that an estimated 12.3 percent or 15.6 million Americans were food insecure,
meaning they had insufficient funds to feed all family members at least some time during the year in 2016[1].

Figure : Social-Ecological Model.

Image by Allison Calabrese / CC BY 4.0

Recommendations for Optimal Health

For many years, the US government has been encouraging Americans to develop healthful dietary habits. In 1992 the Food
Pyramid was introduced, and in 2005 it was updated. This was the symbol of healthy eating patterns for all Americans. However,
some felt it was difficult to understand, so in 2011, the pyramid was replaced with MyPlate.
The MyPlate program uses a tailored approach to give people the needed information to help design a healthy diet. The plate is
divided according to the amount of food and nutrients you should consume for each meal. Each food group is identified with a
different color, showing the food variety that all plates must have. Aside from educating people about the type of food that is best to
support optimal health, the new food plan offers the advice that it is okay to enjoy food, just eat a diverse diet and in moderation[2].

 Everyday Connections

Interested in another reliable source for nutrition and health information? The “Got Nutrients?” website highlights the
importance of meeting essential nutrient needs in order to maintain optimum health. This website, geared for those interested in
nutrition, fitness, and health, posts short daily nutrition and health messages. Each short “Daily Tip” includes links to both a
popular article and to a related scientific resource. For more information about “Got Nutrients?” visit,
[Link] To receive the “Daily Tips” by email, visit [Link]

2.9.1 [Link]
 Figure : Image by Got Nutrients?/ Got Nutrients website

References
1. Food Security in the U.S. United States Department of Agriculture, Economic Research Service.
[Link] Updated
September 6, 2017. Accessed November 22, 2017. ↵
2. Choose MyPlate. US Department of Agriculture. [Link] Accessed July 22, 2012. ↵

This page titled 2.9: Building Healthy Eating Patterns is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by
Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
12.4: Building Healthy Eating Patterns by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA
4.0. Original source: [Link]

2.9.2 [Link]
2.10: When Enough is Enough
Learning Objectives
Judge food portion sizes for adequacy.

Estimating Portion Size

Have you ever heard the expression, “Your eyes were bigger than your stomach?” This means that you thought you wanted a lot
more food than you could actually eat. Amounts of food can be deceiving to the eye, especially if you have nothing to compare
them to. It is very easy to heap a pile of mashed potatoes on your plate, particularly if it is a big plate, and not realize that you have
just helped yourself to three portions instead of one.
The food industry makes following the 2010 Dietary Guidelines a challenge. In many restaurants and eating establishments,
portion sizes have increased, use of SoFAS has increased, and consequently the typical meal contains more calories than it used to.
In addition, our sedentary lives make it difficult to expend enough calories during normal daily activities. In fact, more than one-
third of adults are not physically active at all.

Figure : As food sizes and servings increase it is important

to limit the portions of food consumed on a regular basis.
Dietitians have come up with some good hints to help people tell how large a portion of food they really have. Some suggest using
common items such as a deck of cards while others advocate using your hand as a measuring rule. See Table for some
[Link] Cancer Society. “Controlling Portion Sizes.” Last revised January 12, 2012.
[Link]
Table : Determining Food Portions

Food Product Amount Object Comparison Hand Comparison

Pasta, rice ½ c. Tennis ball Cupped hand

Fresh vegetables 1 c. Baseball

Cooked vegetables ½ c. Cupped hand

Meat, poultry, fish 3 oz. Deck of cards Palm of your hand

Milk or other beverages 1 c. Fist

Salad dressing 1 Tbsp. Thumb

Oil 1 tsp. Thumb tip

Video : Managing a Healthy Diet: Judging Healthy Portion Sizes

2.10.1 [Link]
 A dietitian shows how to compare food sizes with hands and other objects.(click to see video)

MyPlate Planner
Estimating portions can be done using the MyPlate Planner. Recall that the MyPlate symbol is divided according to how much of
each food group should be included with each meal. Note the MyPlate Planner Methods of Use:
Fill half of your plate with vegetables such as carrots, broccoli, salad, and fruit.
Fill one-quarter of your plate with lean meat, chicken, or fish (about 3 ounces)
Fill one-quarter of your plate with a whole grain such as ⅓ cup rice
Choose one serving of dairy
Add margarine or oil for preparation or addition at the table
Table : Meal Planning Guidelines

Carbohydrates Meats/Proteins Fats Free Foods

Choose three servings with Choose one to three servings Choose one to two servings
Use as desired.
each meal. with each meal. with each meal.

Examples of one serving: Examples of one serving: Examples of one serving: Examples

Breads and Starches

1 slice bread or small roll 1 oz. lean meat, poultry, or Foods with less than 20
1 tsp. margarine, oil, or
⅓ c. rice or pasta fish calories per serving.*
mayonnaise
½ c. of cooked cereal or 1 egg Most vegetables
1 Tbsp. salad dressing or
potatoes 1 oz. cheese Sugar-free soda
cream cheese
¾ c. dry cereal ¾ c. low-fat cottage cheese Black coffee or plain tea
½ c. corn

Fruits
1 piece, such as a small pear
1 c. fresh fruit
½ c. canned fruit
½ c. fruit juice

Milk
1 c. skim or low fat
1 c. unsweetened low-fat
yogurt

2.10.2 [Link]
Key Takeaways
Judging portion sizes can be done using your hand or household objects in comparison. It can also be done using the MyPlate
guide to determine how much food is a portion for that meal.

Discussion Starter
1. Why is it important to judge portion sizes properly? Explain why it can be tricky to read food labels and figure out the caloric
content for one serving.

2.10: When Enough is Enough is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

2.10.3 [Link]
2.11: Nutrition and the Media
Learning Objectives
List at least four sources of reliable and accurate nutrition information.

A motivational speaker once said, “A smart person believes half of what they read. An intelligent person knows which half to
believe.” In this age of information where instant Internet access is just a click away, it is easy to be misled if you do not know
where to go for reliable nutrition information. There are a few websites that can be consistently relied upon for accurate material
that is updated regularly.

Figure : Right information or wrong information? How can you

know? © Shutterstock

Using Eyes of Discernment

“New study shows that margarine contributes to arterial plaque.” “Asian study reveals that two cups of coffee per day can have
detrimental effects on the nervous system.” How do you react when you read news of this nature? Do you boycott margarine and
coffee? When reading nutrition-related claims, articles, websites, or advertisements always remember that one study does not
substantiate a fact. One study neither proves nor disproves anything. Readers who may be looking for complex answers to
nutritional dilemmas can quickly misconstrue such statements and be led down a path of misinformation. Listed below are ways
that you can develop discerning eyes when reading nutritional news.
1. The scientific study under discussion should be published in a peer-reviewed journal, such as the Journal of the International
Society of Sports Nutrition. Question studies that come from less trustworthy sources (such as non peer-reviewed journals or
websites) or that are not published.
2. The report should disclose the methods used by the researcher(s). Did the study last for three or thirty weeks? Were there ten or
one hundred participants? What did the participants actually do? Did the researcher(s) observe the results themselves or did they
rely on self reports from program participants?
3. Who were the subjects of this study? Humans or animals? If human, are any traits/characteristics noted? You may realize you
have more in common with certain program participants and can use that as a basis to gauge if the study applies to you.
4. Credible reports often disseminate new findings in the context of previous research. A single study on its own gives you very
limited information, but if a body of literature supports a finding, it gives you more confidence in it.
5. Peer-reviewed articles deliver a broad perspective and are inclusive of findings of many studies on the exact same subject.
6. When reading such news, ask yourself, “Is this making sense?” Even if coffee does adversely affect the nervous system, do you
drink enough of it to see any negative effects? Remember, if a headline professes a new remedy for a nutrition-related topic, it
may well be a research-supported piece of news, but more often than not it is a sensational story designed to catch the attention
of an unsuspecting consumer. Track down the original journal article to see if it really supports the conclusions being drawn in
the news report.
When reading information on websites, remember the following criteria for discerning if the site is valid:
1. Who sponsors the website?

2.11.1 [Link]
 2. Are names and credentials disclosed?
3. Is an editorial board identified?
4. Does the site contain links to other credible informational websites? Even better, does it reference peer-reviewed journal
articles? If so, do those journal articles actually back up the claims being made on the website?
5. How often is the website updated?
6. Are you being sold something at this website?
7. Does the website charge a fee?

Trustworthy Sources
Now let’s consider some reputable organizations and websites from which you can obtain valid nutrition information.
1. Centers for Disease Control and Prevention (CDC): The Centers for Disease Control and Prevention ([Link]
distributes an online newsletter called CDC Vital Signs. This newsletter is a valid and credible source for up-to-date public
health information and data regarding food, nutrition, cholesterol, high blood pressure, obesity, teenage drinking, and tobacco
usage.
2. The Academy of Nutrition and Dietetics (AND): The AND promotes scientific evidenced-based, research-supported food and
nutrition related information on its website, [Link] It is focused on informing the public about recent scientific
discoveries and studies, weight-loss concerns, food safety topics, nutrition issues, and disease prevention.
3. US Department of Agriculture (USDA): The USDA site [Link] has more than twenty-five hundred links to dietary,
nutrition, diet and disease, weight and obesity, food-safety and food-labeling, packaging, dietary supplement and consumer
questions sites. Using this interactive site, you can find tips and resources on how to eat a healthy diet, my Foodapedia, and a
food planner, among other sections.
4. US Department of Health and Human Services (HHS): The HHS website, [Link], provides credible information
about healthful lifestyles and the latest in health news. A variety of online tools are available to assist with food-planning,
weight maintenance, physical activity, and dietary goals. You can also find healthful tips for all age groups, tips for preventing
disease, and on daily health issues in general.
5. Dietitians of Canada: Dietitians of Canada, [Link] is the national professional association for dietitians. It
provides trusted nutrition information to Canadians and health professionals.
6. Health Canada: Health Canada, [Link] is the Federal department that helps Canadians
improve their health. Its website also provides information about health-related legislation.

Key Takeaways
Reliable nutritional news will be based upon solid scientific evidence, supported by multiple studies, and published in peer-
reviewed journals. Be sure the website you use for information comes from a credible and trustworthy source, such as the
USDA Food and Nutrition Center, the HHS, and the CDC.

Discussion Starter
1. Discuss why it is important to get information from proper and credible sources and not to rely upon single study findings.

2.11: Nutrition and the Media is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

2.11.2 [Link]
 CHAPTER OVERVIEW

3: The Human Body

Learning Objectives
By the end of this chapter, you will be able to:
Explain the anatomy and physiology of the digestive system and other supporting organ systems
Describe the relationship between diet and each of the organ systems
Describe the process of calculating Body Mass Index (BMI)

3.1: Introduction to the Human Body

3.2: The Basic Structural and Functional Unit of Life- The Cell
3.3: Basic Biology, Anatomy, and Physiology
3.4: The Digestive System
3.4.1: Digestion and Absorption
3.5: The Cardiovascular System
3.6: Central Nervous System
3.7: The Respiratory System
3.8: The Endocrine System
3.9: The Urinary System
3.10: The Muscular System
3.11: The Skeletal System
3.12: The Immune System
3.13: Indicators of Health- Body Mass Index, Body Fat Content, and Fat Distribution

This page titled 3: The Human Body is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper,
Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.

1
3.1: Introduction to the Human Body
I ola no ke kino i ka māʻona o ka ʻōpū
The body enjoys health when the stomach is full

Figure : Image by Henrique Felix on [Link] / CC0

The Native Hawaiians believed there was a strong connection between health and food. Around the world, other cultures had
similar views of food and its relationship with health. A famous quote by the Greek physician Hippocrates over two thousand years
ago, “Let food be thy medicine and medicine be thy food” bear much relevance on our food choices and their connection to our
health. Today, the scientific community echoes Hippocrates’ statement as it recognizes some foods as functional foods. The
Academy of Nutrition and Dietetics defines functional foods as “whole foods and fortified, enriched, or enhanced foods that have a
potentially beneficial effect on health when consumed as part of a varied diet on a regular basis, at effective levels.”
In the latter nineteenth century, a Russian doctor of immunology, Elie Metchnikoff, was intrigued by the healthy life spans of
people who lived in the tribes of the northern Caucasus Mountains. What contributed to their long lifespan and their resistance to
life-threatening diseases? A possible factor lay wrapped up in a leather satchel used to hold fermented milk. Observing the
connection between the beverage and longevity, Dr. Elie Metchnikoff began his research on beneficial bacteria and the longevity of
life that led to his book, The Prolongation of Life. He studied the biological effects and chemical properties of the kefir elixir
whose name came from the Turkish word “kef” or “pleasure.” To this day, kefir is one of the most widely enjoyed beverages in
Russia.
Kefir has since found its way into America, where it is marketed in several flavors and can be found at your local grocery store. It
is one product of the billion-dollar functional food industry marketed with all sorts of health claims from improving digestion to
preventing cancer. What is the scientific evidence that kefir is a functional food? Expert nutritionists agree that probiotics, such as
kefir, reduce the symptoms of lactose intolerance and can ward off virally caused diarrhea. While some health claims remain
unsubstantiated, scientific studies are ongoing to determine the validity of other health benefits of probiotics.
The Native Hawaiians also consumed a daily probiotic in their diet commonly known as poi (pounded taro). In precolonial
Hawai‘i, poi was used for a wide variety of dietary and medicinal purposes. Aside from poi’s nutrient dense composition,
fermented poi has numerous compounds created in the fermentation process that are very beneficial to the health of the human
body. As a probiotic, evidence suggests that poi can be useful in helping diseases such as diarrhea, gastroenteritis, irritable bowel
syndrome, inflammatory bowel disease, and cancer.[1]
Another well-known probiotic to the local people of Hawai‘i is Kimchi. Kimchi is a traditional Korean food that is manufactured
by fermenting vegetables (usually cabbage). Similar to the kefir and poi, kimchi also has shown to have similar health benefits as a
probiotic food.[2]
The Japanese also have traditional fermented foods such as natto. Natto is made from fermented soybeans and has many health
benefits as a probiotic. Along with the beneficial components, natto is very nutrient-dense containing carbohydrates, fats, protein,
fiber, vitamins and minerals.[3] Other common foods we ferment in our diet include miso, sauerkraut, kombucha, and tempeh.

3.1.1 [Link]
 Figure : Components of Organ Systems in the Human
Body. Digestive system without labels by Mariana Ruiz / Public Domain
Knowing how to maintain the balance of friendly bacteria in your intestines through proper diet can promote overall health. Recent
scientific studies have shown that probiotic supplements positively affect intestinal microbial flora, which in turn positively affect
immune system function. As good nutrition is known to influence immunity, there is great interest in using probiotic foods and
other immune-system-friendly foods as a way to prevent illness. In this chapter we will explore not only immune system function,
but also all other organ systems in the human body. We will learn the process of nutrient digestion and absorption, which further
reiterates the importance of developing a healthy diet to maintain a healthier you. The evidence abounds that food can indeed be
“thy medicine.”
1. Brown A, Valiere A. (2004). The Medicinal Uses of Poi. Nutrition in Clinical Care, 7(2), 69-74.
[Link]
2. Park K, Jeong J, et al. (2014). Health Benefits of Kimchi. Journal of Medicinal Food, 17(1), 6-20.
[Link]
3. Sanjukta S, Rai AK. (2016). Production of bioactive peptides during soy fermentation and their potential health benefits. Trends
in Food Science and Technology, 50, 1-10. [Link]

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Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
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4.0. Original source: [Link]

3.1.2 [Link]
3.2: The Basic Structural and Functional Unit of Life- The Cell
Learning Objectives
Diagram the components of a cell.
Describe the organization of the human body.

What distinguishes a living organism from an inanimate object? A living organism conducts self-sustaining biological processes. A
cell is the smallest and most basic form of life. Robert Hooke, one of the first scientists to use a light microscope, discovered the
cell in 1665. In all life forms, including bacteria, plants, animals, and humans, the cell was defined as the most basic structural and
functional unit. Based on scientific observations over the next 150 years, scientists formulated the cell theory, which is used for all
living organisms no matter how simple or complex. The cell theory incorporates three principles:
Cells are the most basic building units of life.
All living things are composed of cells.
New cells are made from preexisting cells, which divide into two.
Who you are has been determined because of two cells that came together inside your mother’s womb. The two cells containing all
of your genetic information (DNA) united to begin making new life. Cells divided and differentiated into other cells with specific
roles that led to the formation of the body’s numerous body organs, systems, blood, blood vessels, bone, tissue, and skin. As an
adult, you are comprised of trillions of cells. Each of your individual cells is a compact and efficient form of life—self-sufficient,
yet interdependent upon the other cells within your body to supply its needs.

One cell divides into two, which begins the creation of millions of more cells that ultimately become you. (Public Domain; National
Institutes of Health).
Independent single-celled organisms must conduct all the basic processes of life: it must take in nutrients (energy capture), excrete
wastes, detect and respond to its environment, move, breathe, grow, and reproduce. Even a one-celled organism must be organized
to perform these essential processes. All cells are organized from the atomic level to all its larger forms. Oxygen and hydrogen
atoms combine to make the molecule water (H2O). Molecules bond together to make bigger macromolecules. The carbon atom is
often referred to as the backbone of life because it can readily bond with four other elements to form long chains and more complex
macromolecules. Four macromolecules—carbohydrates, lipids, proteins, and nucleic acids—make up all of the structural and
functional units of cells.

3.2.1 [Link]
 Figure : The cell is structurally and functionally complex.
Although we defined the cell as the “most basic” unit of life, it is structurally and functionally complex (Figure ). A cell can be
thought of as a mini-organism consisting of tiny organs called organelles. The organelles are structural and functional units
constructed from several macromolecules bonded together. A typical animal cell contains the following organelles: the nucleus
(which houses the genetic material DNA), mitochondria (which generate energy), ribosomes (which produce protein), the
endoplasmic reticulum (which is a packaging and transport facility), and the golgi apparatus (which distributes macromolecules). In
addition, animal cells contain little digestive pouches, called lysosomes and peroxisomes, which break down macromolecules and
destroy foreign invaders. All of the organelles are anchored in the cell’s cytoplasm via a cytoskeleton. The cell’s organelles are
isolated from the surrounding environment by a plasma membrane.

Video 3.1: Discovery Video: Cells

This video describes the importance of cells in the human body.

Discovery Video - Cells

Tissues, Organs, Organ Systems, and Organisms

Unicellular (single-celled) organisms can function independently, but the cells of multicellular organisms are dependent upon each
other and are organized into five different levels in order to coordinate their specific functions and carry out all of life’s biological
processes.
Cells. Cells are the basic structural and functional unit of all life. Examples include red blood cells and nerve cells.
Tissues. Tissues are groups of cells that share a common structure and function and work together. There are four types of
human tissues: connective, which connects tissues; epithelial, which lines and protects organs; muscle, which contracts for
movement and support; and nerve, which responds and reacts to signals in the environment.
Organs. Organs are a group of tissues arranged in a specific manner to support a common physiological function. Examples
include the brain, liver, and heart.

3.2.2 [Link]
Organ systems. Organ systems are two or more organs that support a specific physiological function. Examples include the
digestive system and central nervous system. There are eleven organ systems in the human body (Table ).
Organism. An organism is the complete living system capable of conducting all of life’s biological processes.
Table : The Eleven Organ Systems in the Human Body and Their Major Functions

Organ System Organ Components Major Function

Circulatory heart, blood/lymph vessels, blood, lymph Transport nutrients and waste products

Digestive mouth, esophagus, stomach, intestines Digestion and absorption

Endocrine all glands (thyroid, ovaries, pancreas) Produce and release hormones

Immune white blood cells, lymphatic tissue, marrow Defend against foreign invaders

Integumentary skin, nails, hair, sweat glands Protective, body temperature regulation

Muscular skeletal, smooth, and cardiac muscle Body movement

Nervous brain, spinal cord, nerves Interprets and responds to stimuli

Reproductive gonads, genitals Reproduction and sexual characteristics

Respiratory lungs, nose, mouth, throat, trachea Gas exchange

Skeletal bones, tendons, ligaments, joints Structure and support

Urinary kidneys, bladder, ureters Waste excretion, water balance

3.2.3 [Link]
 Figure : Organ Systems in the Human Body ©
Networkgraphics

An Organism Requires Energy and Nutrient Input

Energy is required in order to build molecules into larger macromolecules, and to turn macromolecules into organelles and cells,
and then turn those into tissues, organs, and organ systems, and finally into an organism. Proper nutrition provides the necessary
nutrients to make the energy that supports life’s processes. Your body builds new macromolecules from the nutrients in food.

Nutrient and Energy Flow

Energy is stored in a nutrient’s chemical bonds. Energy comes from sunlight, which plants then capture and, via photosynthesis, use
it to transform carbon dioxide in the air into the molecule, glucose. When the glucose bonds are broken, energy is released.
Bacteria, plants, and animals (including humans) harvest the energy in glucose via a biological process called cellular respiration.
In this process the chemical energy of glucose is transformed into cellular energy in the form of the molecule, adenosine
triphosphate (ATP). Cellular respiration requires oxygen (aerobic) and it is provided as a waste product of photosynthesis. The
waste products of cellular respiration are carbon dioxide (CO2) and water, which plants use to conduct photosynthesis again. Thus,
energy is constantly cycling between plants and animals. As energy is consumed nutrients are recycled within it.

3.2.4 [Link]
Plants harvest energy from the sun and capture it in the molecule, glucose. Humans harvest the energy in glucose and capture it
into the molecule, ATP.
In this section, we have learned that all life is composed of cells capable of transforming small organic molecules into energy. How
do complex organisms such as humans convert the large macromolecules in the foods that we eat into molecules that can be used
by cells to make cellular energy? In the next section, we will discuss the physiological process of digestion to answer this question.

Key Takeaways
The cell is the basic structural and functional unit of life. Cells are independent, single-celled organisms that take in nutrients,
excrete wastes, detect and respond to their environment, move, breathe, grow, and reproduce. The macromolecules
carbohydrates, proteins, lipids, and nucleic acids make up all of the structural and functional units of cells.
In complex organisms, cells are organized into five levels so that an organism can conduct all basic processes associated with
life.
There are eleven organ systems in the human body that work together to support life, all of which require nutrient input.
Energy is constantly cycling between plants and animals. As energy is consumed nutrients are recycled within it.

Discussion Starter
1. Discuss the importance of organization in the human body. If the body becomes disorganized by a disease or disorder what
happens to its function? Can you think of a good example (what about leg fracture and movement)?

3.2: The Basic Structural and Functional Unit of Life- The Cell is shared under a CC BY-NC-SA license and was authored, remixed, and/or
curated by LibreTexts.

3.2.5 [Link]
3.3: Basic Biology, Anatomy, and Physiology
The Basic Structural and Functional Unit of Life: The Cell
What distinguishes a living organism from an inanimate object? A living organism conducts self-sustaining biological processes. A
cell is the smallest and most basic form of life.
The cell theory incorporates three principles:
Cells are the most basic building units of life. All living things are composed of cells. New cells are made from preexisting cells,
which divide in two. Who you are has been determined because of two cells that came together inside your mother’s womb. The
two cells containing all of your genetic information (DNA) united to begin making new life. Cells divided and differentiated into
other cells with specific roles that led to the formation of the body’s numerous body organs, systems, blood, blood vessels, bone,
tissue, and skin. As an adult, you are made up of trillions of cells. Each of your individual cells is a compact and efficient form of
life—self-sufficient, yet interdependent upon the other cells within your body to supply its needs.
Independent single-celled organisms must conduct all the basic processes of life. The single-celled organism must take in
nutrients (energy capture), excrete wastes, detect and respond to its environment, move, breathe, grow, and reproduce. Even a one-
celled organism must be organized to perform these essential processes. All cells are organized from the atomic level to all its
larger forms. Oxygen and hydrogen atoms combine to make the molecule water ( ). Molecules bond together to make bigger
macromolecules. The carbon atom is often referred to as the backbone of life because it can readily bond with four other elements
to form long chains and more complex macromolecules. Four macromolecules—carbohydrates, lipids, proteins, and nucleic acids
—make up all of the structural and functional units of cells.
Although we defined the cell as the “most basic” unit of life, it is structurally and functionally complex (Figure ). A cell
can be thought of as a mini-organism consisting of tiny organs called organelles. The organelles are structural and functional units
constructed from several macromolecules bonded together. A typical animal cell contains the following organelles: the nucleus
(which houses the genetic material DNA), mitochondria (which generate energy), ribosomes (which produce protein), the
endoplasmic reticulum (which is a packaging and transport facility), and the golgi apparatus (which distributes macromolecules). In
addition, animal cells contain little digestive pouches, called lysosomes and peroxisomes, which break down macromolecules and
destroy foreign invaders. All of the organelles are anchored in the cell’s cytoplasm via a cytoskeleton. The cell’s organelles are
isolated from the surrounding environment by a plasma membrane.

Figure : The Cell Structure. The cell is structurally and functionally

complex.

Tissues, Organs, Organ Systems, and Organisms

Unicellular (single-celled) organisms can function independently, but the cells of multicellular organisms are dependent upon each
other and are organized into five different levels in order to coordinate their specific functions and carry out all of life’s biological
processes (Figure ).

3.3.1 [Link]
 Cells are the basic structural and functional unit of all life. Examples include red blood cells and nerve cells. There are hundreds
of types of cells. All cells in a person contain the same genetic information in DNA. However, each cell only expresses the
genetic codes that relate to the cell’s specific structure and function.
Tissues are groups of cells that share a common structure and function and work together. There are four basic types of human
tissues: connective, which connects tissues; epithelial, which lines and protects organs; muscle, which contracts for movement
and support; and nerve, which responds and reacts to signals in the environment.
Organs are a group of tissues arranged in a specific manner to support a common physiological function. Examples include the
brain, liver, and heart.
Organ systems are two or more organs that support a specific physiological function. Examples include the digestive system
and central nervous system. There are eleven organ systems in the human body (see Table ).
An organism is the complete living system capable of conducting all of life’s biological processes.

Figure : Organization of Life. (CC BY-SA 4.0;

Laia Martinez via Wikipedia)
Table : The Eleven Organ Systems in the Human Body and Their Major Functions

3.3.2 [Link]
 Organ System Organ Components Major Function

Cardiovascular heart, blood/lymph vessels, blood, lymph Transport nutrients and waste products

Digestive mouth, esophagus, stomach, intestines Digestion and absorption

Endocrine all glands (thyroid, ovaries, pancreas) Produce and release hormones

A one-way system of vessels that transport

Lymphatic tonsils, adenoids, spleen and thymus
lymph throughout the body

Immune white blood cells, lymphatic tissue, marrow Defend against foreign invaders

Integumentary skin, nails, hair, sweat glands Protective, body temperature regulation

Muscular skeletal, smooth, and cardiac muscle Body movement

Nervous brain, spinal cord, nerves Interprets and responds to stimuli

Reproductive gonads, genitals Reproduction and sexual characteristics

Respiratory lungs, nose, mouth, throat, trachea Gas exchange

Skeletal bones, tendons, ligaments, joints Structure and support

Urinary, Excretory kidneys, bladder, ureters Waste excretion, water balance

This page titled 3.3: Basic Biology, Anatomy, and Physiology is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or
curated by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
2.2: Basic Biology, Anatomy, and Physiology by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-
NC-SA 4.0. Original source: [Link]

3.3.3 [Link]
3.4: The Digestive System
The process of digestion begins even before you put food into your mouth. When you feel hungry, your body sends a message to
your brain that it is time to eat. Sights and smells influence your body’s preparedness for food. Smelling food sends a message to
your brain. Your brain then tells the mouth to get ready, and you start to salivate in preparation for a meal.
Once you have eaten, your digestive system (Figure ) starts the process that breaks down the components of food into smaller
components that can be absorbed and taken into the body. To do this, the digestive system functions on two levels, mechanically to
move and mix ingested food and chemically to break down large molecules. The smaller nutrient molecules can then be absorbed
and processed by cells throughout the body for energy or used as building blocks for new cells. The digestive system is one of the
eleven organ systems of the human body, and it is composed of several hollow tube-shaped organs including the mouth, pharynx,
esophagus, stomach, small intestine, large intestine (colon), rectum, and anus. It is lined with mucosal tissue that secretes digestive
juices (which aid in the breakdown of food) and mucus (which facilitates the propulsion of food through the tract). Smooth muscle
tissue surrounds the digestive tract and its contraction produces waves, known as peristalsis, that propel food down the tract.
Nutrients, as well as some non-nutrients, are absorbed. Substances such as fiber get left behind and are appropriately excreted.

Figure : Digestion Breakdown of Macronutrients. 3 molecules of Glucose, Lipids

becomes 1 molecule of fatty acids and and one molecule of glycerol, and Proteins become 3 molecules of Amino Acids
Digestion converts components of the food we eat into smaller molecules that can be absorbed into the body and utilized for energy
needs or as building blocks for making larger molecules in cells.

 Everyday Connection

There has been significant talk about pre- and probiotic foods in the mainstream media. The World Health Organization defines
probiotics as live bacteria that confer beneficial health effects on their host. They are sometimes called “friendly bacteria.” The
most common bacteria labeled as probiotic is lactic acid bacteria (lactobacilli). They are added as live cultures to certain
fermented foods such as yogurt. Prebiotics are indigestible foods, primarily soluble fibers, that stimulate the growth of certain
strains of bacteria in the large intestine and provide health benefits to the host. A review article in the June 2008 issue of the
Journal of Nutrition concludes that there is scientific consensus that probiotics ward off viral-induced diarrhea and reduce the
symptoms of lactose intolerance.[1]

Figure : Image by Gabriel Lee / CC BY-NC-SA

Expert nutritionists agree that more health benefits of pre- and probiotics will likely reach scientific consensus. As the fields of
pre- and probiotic manufacturing and their clinical study progress, more information on proper dosing and what exact strains of

3.4.1 [Link]
 bacteria are potentially “friendly” will become available.
You may be interested in trying some of these foods in your diet. A simple food to try is kefir. Several websites provide good
recipes, including [Link]/[Link]. Kefir, a dairy product fermented with probiotic bacteria, can make a pleasant
tasting milkshake.

From the Mouth to the Stomach

There are four steps in the digestion process (Figure ). The first step is ingestion, which is the intake of food into the digestive
tract. It may seem a simple process, but ingestion involves smelling food, thinking about food, and the involuntary release of saliva
in the mouth to prepare for food entry. In the mouth, where the second step of digestion starts, the mechanical and chemical
breakdown of food begins. The chemical breakdown of food involves enzymes, such as salivary amylase that starts the breakdown
of large starch molecules into smaller components.

Figure : The
Human Digestive System. Image by Allison Calabrese / CC BY 4.0
Mechanical breakdown starts with mastication (chewing) in the mouth. Teeth crush and grind large food particles, while saliva
provides lubrication and enables food movement downward. The slippery mass of partially broken-down food is called a bolus,
which moves down the digestive tract as you swallow. Swallowing may seem voluntary at first because it requires conscious effort
to push the food with the tongue back toward the throat, but after this, swallowing proceeds involuntarily, meaning it cannot be
stopped once it begins. As you swallow, the bolus is pushed from the mouth through the pharynx and into a muscular tube called
the esophagus. As the bolus travels through the pharynx, a small flap called the epiglottis closes to prevent choking by keeping
food from going into the trachea. Peristaltic contractions also known as peristalsis in the esophagus propel the food bolus down to
the stomach (Figure ). At the junction between the esophagus and stomach there is a sphincter muscle that remains closed until
the food bolus approaches. The pressure of the food bolus stimulates the lower esophageal sphincter to relax and open and food
then moves from the esophagus into the stomach. The mechanical breakdown of food is accentuated by the muscular contractions
of the stomach and small intestine that mash, mix, slosh, and propel food down the alimentary canal. Solid food takes between four
and eight seconds to travel down the esophagus, and liquids take about one second.

3.4.2 [Link]
 Figure : Peristalsis in the Esophagus. Image by
Allison Calabrese / CC BY 4.0

From the Stomach to the Small Intestine

When food enters the stomach, a highly muscular organ, powerful peristaltic contractions help mash, pulverize, and churn food into
chyme. Chyme is a semiliquid mass of partially digested food that also contains gastric juices secreted by cells in the stomach.
These gastric juices contain hydrochloric acid and the enzyme pepsin, that chemically start breakdown of the protein components
of food.
The length of time food spends in the stomach varies by the macronutrient composition of the meal. A high-fat or high-protein meal
takes longer to break down than one rich in carbohydrates. It usually takes a few hours after a meal to empty the stomach contents
completely into the small intestine.
The small intestine is divided into three structural parts: the duodenum, the jejunum, and the ileum. Once the chyme enters the
duodenum (the first segment of the small intestine), the pancreas and gallbladder are stimulated and release juices that aid in
digestion. The pancreas secretes up to 1.5 liters (0.4 US gallons) of pancreatic juice through a duct into the duodenum per day. This
fluid consists mostly of water, but it also contains bicarbonate ions that neutralize the acidity of the stomach-derived chyme and
enzymes that further break down proteins, carbohydrates, and lipids. The gallbladder secretes a much smaller amount of a fluid
called bile that helps to digest fats. Bile passes through a duct that joins the pancreatic ducts and is released into the duodenum.
Bile is made in the liver and stored in the gall bladder. Bile’s components act like detergents by surrounding fats similar to the way
dish soap removes grease from a frying pan. This allows for the movement of fats in the watery environment of the small intestine.
Two different types of muscular contractions, called peristalsis and segmentation, control the movement and mixing of the food in
various stages of digestion through the small intestine.
Similar to what occurs in the esophagus and stomach, peristalsis is circular waves of smooth muscle contraction that propel food
forward. Segmentation from circular muscle contraction slows movement in the small intestine by forming temporary “sausage
link” type of segments that allows chyme to slosh food back and forth in both directions to promote mixing of the chyme and
enhance absorption of nutrients (Figure ). Almost all the components of food are completely broken down to their simplest
units within the first 25 centimeters of the small intestine. Instead of proteins, carbohydrates, and lipids, the chyme now consists of
amino acids, monosaccharides, and emulsified components of triglycerides.

3.4.3 [Link]
 Figure : Segmentation. “Segmentation” by OpenStax College / CC BY 3.0
The third step of digestion (nutrient absorption) takes place mainly in the remaining length of the small intestine, or ileum (> 5
meters). The way the small intestine is structured gives it a huge surface area to maximize nutrient absorption. The surface area is
increased by folds, villi, and microvilli. Digested nutrients are absorbed into either capillaries or lymphatic vessels contained within
each microvillus.
The small intestine is perfectly structured for maximizing nutrient absorption. Its surface area is greater than 200 square meters,
which is about the size of a tennis court. The large surface area is due to the multiple levels of folding. The internal tissue of the
small intestine is covered in villi, which are tiny finger-like projections that are covered with even smaller projections, called
microvilli (Figure ). The digested nutrients pass through the absorptive cells of the intestine via diffusion or special transport
proteins. Amino acids, short fatty acids, and monosaccharides (sugars) are transported from the intestinal cells into capillaries, but
the larger fatty acids, fat-soluble vitamins, and other lipids are transported first through lymphatic vessels, which soon meet up with
blood vessels.

Figure : Structure of the Small

Intestine. “Histology Small Intestines” by OpenStax College / CC BY 3.0

3.4.4 [Link]
From the Small Intestine to the Large Intestine
The process of digestion is fairly efficient. Any food that is still incompletely broken down (usually less than ten percent of food
consumed) and the food’s indigestible fiber content move from the small intestine to the large intestine (colon) through a
connecting valve. A main task of the large intestine is to absorb much of the remaining water. Remember, water is present not only
in solid foods and beverages, but also the stomach releases a few hundred milliliters of gastric juice, and the pancreas adds
approximately 500 milliliters during the digestion of the meal. For the body to conserve water, it is important that excessive water
is not lost in fecal matter. In the large intestine, no further chemical or mechanical breakdown of food takes place unless it is
accomplished by the bacteria that inhabit this portion of the intestinal tract. The number of bacteria residing in the large intestine is
estimated to be greater than 1014, which is more than the total number of cells in the human body (1013). This may seem rather
unpleasant, but the great majority of bacteria in the large intestine are harmless and many are even beneficial.

From the Large Intestine to the Anus

After a few hours in the stomach, plus three to six hours in the small intestine, and about sixteen hours in the large intestine, the
digestion process enters step four, which is the elimination of indigestible food matter as feces. Feces contain indigestible food
components and gut bacteria (almost 50 percent of content). It is stored in the rectum until it is expelled through the anus via
defecation.

Nutrients Are Essential for Cell and Organ Function

When the digestive system has broken down food to its nutrient components, the body eagerly awaits delivery. Water soluble
nutrients absorbed into the blood travel directly to the liver via a major blood vessel called the portal vein. One of the liver’s
primary functions is to regulate metabolic homeostasis. Metabolic homeostasis is achieved when the nutrients consumed and
absorbed match the energy required to carry out life’s biological processes. Simply put, nutrient energy intake equals energy output.
Whereas glucose and amino acids are directly transported from the small intestine to the liver, lipids are transported to the liver by
a more circuitous route involving the lymphatic system. The lymphatic system is a one-way system of vessels that transports
lymph, a fluid rich in white blood cells, and lipid soluble substances after a meal containing lipids. The lymphatic system slowly
moves its contents through the lymphatic vessels and empties into blood vessels in the upper chest area. Now, the absorbed lipid
soluble components are in the blood where they can be distributed throughout the body and utilized by cells (Figure ).

3.4.5 [Link]
 Figure : The Absorption of Nutrients. Image by
Allison Calabrese / CC BY 4.0
Maintaining the body’s energy status quo is crucial because when metabolic homeostasis is disturbed by an eating disorder or
disease, bodily function suffers. This will be discussed in more depth in the last section of this chapter. The liver is the only organ
in the human body that is capable of exporting nutrients for energy production to other tissues. Therefore, when a person is in
between meals (fasted state) the liver exports nutrients, and when a person has just eaten (fed state) the liver stores nutrients within
itself. Nutrient levels and the hormones that respond to their levels in the blood provide the input so that the liver can distinguish
between the fasted and fed states and distribute nutrients appropriately. Although not considered to be an organ, adipose tissue
stores fat in the fed state and mobilizes fat components to supply energy to other parts of the body when energy is needed.
All eleven organ systems in the human body require nutrient input to perform their specific biological functions. Overall health and
the ability to carry out all of life’s basic processes is fueled by energy-supplying nutrients (carbohydrate, fat, and protein). Without
them, organ systems would fail, humans would not reproduce, and the race would disappear. In this section, we will discuss some
of the critical nutrients that support specific organ system functions.
1. Farnworth ER. (2008). The Evidence to Support Health Claims for Probiotics. Journal of Nutrition, 138(6), 1250S–4S.
[Link]/content/138/6/[Link]↵

This page titled 3.4: The Digestive System is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer
Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts
platform.
2.3: The Digestive System by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original
source: [Link]

3.4.6 [Link]
3.4.1: Digestion and Absorption
Learning Objectives
Sketch and label the major organs of the digestive system and state their functions.

Digestion begins even before you put food into your mouth. When you feel hungry, your body sends a message to your brain that it
is time to eat. Sights and smells influence your body’s preparedness for food. Smelling food sends a message to your brain. Your
brain then tells the mouth to get ready, and you start to salivate in preparation for a delicious meal.

Figure : The Digestion Process. Digestion converts the food we eat into smaller
particles, which will be processed into energy or used as building blocks
Once you have eaten, your digestive system (Figure ) breaks down the food into smaller components. Another word for the
breakdown of complex molecules into smaller, simpler molecules is "catabolism" or a "catabolic reaction". To do this, catabolism
functions on two levels, mechanical and chemical. Once the smaller particles have been broken down, they will be absorbed into
the blood and delivered to cells throughout the body for energy or for building blocks needed for cells to function. The digestive
system is one of the eleven organ systems of the human body and it is composed of several hollow tube-shaped organs including
the mouth, pharynx, esophagus, stomach, small intestine, large intestine (or colon), rectum, and anus. It is lined with mucosal tissue
that secretes digestive juices (which aid in the breakdown of food) and mucus (which facilitates the propulsion of food through the
tract). Smooth muscle tissue surrounds the digestive tract and its contraction produces waves, known as peristalsis, that propel food
down the tract. Nutrients as well as some non-nutrients are absorbed. Substances such as fiber get left behind and are appropriately
excreted.

From the Mouth to the Stomach

There are four steps in the digestion process (Figure ). The first step is ingestion, which is the collection of food into the
digestive tract. It may seem a simple process, but ingestion involves smelling food, thinking about food, and the involuntary release
of saliva in the mouth to prepare for food entry. In the mouth, where the second step of digestion occurs, the mechanical and
chemical breakdown of food begins. The chemical breakdown of food involves enzymes, which break apart the components in
food. Theses enzymes are secreted by the salivary glands, stomach, pancreas, and small intestine. Mechanical breakdown starts
with mastication (chewing) in the mouth. Teeth crush and grind large food particles, while saliva initiates the chemical breakdown
of food and enables its movement downward. The slippery mass of partially broken-down food is called bolus, which moves down
the digestive tract as you swallow. Swallowing may seem voluntary at first because it requires conscious effort to push the food
with the tongue back toward the throat, but after this, swallowing proceeds involuntarily, meaning it cannot be stopped once it
begins.

[Link] [Link]
 Figure : Components of the Human Digestive
System. All digestive organs play integral roles in the life-sustaining process of digestion. (CC BY 3.0; OpenStax).
As you swallow, the bolus is pushed from the mouth through the pharynx and into a muscular tube called the esophagus. As it
travels through the pharynx, a small flap called the epiglottis closes, to prevent choking by keeping food from going into the
trachea. Peristaltic contractions in the esophagus propel the food down to the stomach. At the junction between the esophagus and
stomach there is a sphincter muscle that remains closed until the food bolus approaches. The pressure of the food bolus stimulates
the lower esophageal sphincter to relax and open and food then moves from the esophagus into the stomach. The mechanical
breakdown of food is accentuated by the muscular contractions of the stomach and small intestine that mash, mix, slosh, and propel
food down the alimentary canal. Solid food takes between four and eight seconds to travel down the esophagus, and liquids take
about one second.

From the Stomach to the Small Intestine

When food enters the stomach, a highly muscular organ, powerful peristaltic contractions help mash, pulverize, and churn food into
chyme. Chyme is a semiliquid mass of partially digested food that also contains gastric juices secreted by cells in the stomach.
Cells in the stomach also secrete hydrochloric acid and the enzyme pepsin, that chemically breaks down food into smaller
molecules. The stomach has three basic tasks:
1. To store food
2. To mechanically and chemically break down food
3. To empty partially broken-down food into the small intestine
The length of time food spends in the stomach varies by the macronutrient composition of the meal. A high-fat or high-protein meal
takes longer to break down than one rich in carbohydrates. It usually takes a few hours after a meal to empty the stomach contents
completely.

[Link] [Link]
 Video : Digestion Video

This video shows the mechanical and chemical breakdown of food into chyme.

The food machine

Video : the food machine - great endoscopic images, xray and

ultrasound images of food being digested (pretty graphic). Great visuals!
Also talks about energy from food

The small intestine is divided into three structural parts: the duodenum (the top), the jejunum (the middle), and the ileum (the last
part). Once the chyme enters the duodenum (the first segment of the small intestine), three accessory (or helper) organs: liver,
pancreas and gallbladder are stimulated to release juices that aid in digestion. The pancreas secretes up to 1.5 liters of pancreatic
juice through a duct into the duodenum per day. This fluid consists mostly of water, but it also contains bicarbonate ions that
neutralize the acidity of the stomach-derived chyme and enzymes that further breakdown proteins, carbohydrates, and lipids. The
gallbladder secretes a much smaller amount of bile to help digest fats, also through a duct that leads to the duodenum. Bile is made
in the liver and stored in the gall bladder. Bile’s components act like detergents by surrounding fats similar to the way dish soap
removes grease from a frying pan. This allows for the movement of fats in the watery environment of the small intestine. Two
different types of muscular contractions, called peristalsis and segmentation, move and mix the food in various stages of digestion
through the small intestine. Similar to what occurs in the esophagus and stomach, peristalsis is circular waves of smooth muscle
contraction that propel food forward. Segmentation sloshes food back and forth in both directions promoting further mixing of the
chyme. Almost all the components of food are completely broken down to their simplest unit within the first 25 centimeters of the
small intestine. Instead of proteins, carbohydrates, and lipids, the chyme now consists of amino acids, monosaccharides, and
emulsified fatty acids.
The next step of digestion (nutrient absorption) takes place in the remaining length of the small intestine, or ileum (> 5 meters).

[Link] [Link]
 Figure : The way the small intestine is
structured gives it a huge surface area to maximize nutrient absorption. The surface area is increased by folds, villi, and microvilli.
Digested nutrients are absorbed into either capillaries or lymphatic vessels contained within each microvilli. © Shutterstock
The small intestine is perfectly structured for maximizing nutrient absorption. Its surface area is greater than 200 square meters,
which is about the size of a tennis court. The surface area of the small intestine increases by multiple levels of folding. The internal
tissue of the small intestine is covered in villi, which are tiny finger-like projections that are covered with even smaller projections,
called microvilli (Figure ). The digested nutrients pass through the absorptive cells of the intestine via diffusion or special
transport proteins. Nutrients that are water soluble (dissolve in water) like amino acids and monosaccharides (sugars) are
transported from the intestinal cells into capillaries (blood), but the fat soluble nutrients like fatty acids, fat-soluble vitamins, and
other lipids are transported first through lymphatic vessels (lymph), which soon meet up with blood vessels.

From the Small Intestine to the Large Intestine

The process of digestion is fairly efficient. Any food that is still incompletely broken down (usually less than ten percent of food
consumed) and the food’s indigestible fiber content moves from the small intestine to the large intestine (colon) through a
connecting valve. The main task of the large intestine is to reabsorb water. Remember, water is present not only in solid foods, but
also the stomach releases a few hundred millilters of gastric juice and the pancreas adds approximately another 500 milliliters
during the digestion of the meal. For the body to conserve water, it is important that the water be reabsorbed. In the large intestine,
no further chemical or mechanical breakdown of food takes place, unless it is accomplished by the bacteria that inhabit this portion
of the digestive tract. The number of bacteria residing in the large intestine is estimated to be greater than 10(14), which is more than
the total number of cells in the human body (10(13)). This may seem rather unpleasant, but the great majority of bacteria in the large
intestine are harmless and some are even beneficial.

Kefir

There has been significant talk about pre- and probiotic foods in the mainstream media. The World Health Organization defines
probiotics as live bacteria that confer beneficial health effects on their host. They are sometimes called “friendly bacteria.” The
most common bacteria labeled as probiotic is lactic acid bacteria (lactobacilli). They are added as live cultures to certain
fermented foods such as yogurt. Prebiotics are indigestible foods, primarily soluble fibers, that stimulate the growth of certain
strains of bacteria in the large intestine and provide health benefits to the host. A review article in the June 2008 issue of the
Journal of Nutrition concludes that there is scientific consensus that probiotics ward off viral-induced diarrhea and reduce the
symptoms of lactose [Link], E. R. “The Evidence to Support Health Claims for Probiotics.” J Nutr 138, no. 6
(2008): 1250S–4S. [Link] Expert nutritionists agree that more health benefits of pre-
and probiotics will likely reach scientific consensus. As the fields of pre- and probiotic manufacturing and their clinical study
progress, more information on proper dosing and what exact strains of bacteria are potentially “friendly” will become
available.

[Link] [Link]
 Kefir, a dairy product fermented with probiotic bacteria, can make a pleasant tasting milkshake. (CC BY-SA 3.0; Quijote )
You may be interested in trying some of these foods in your diet. A simple food to try is kefir. Several websites provide good
recipes, including [Link]/[Link].

From the Large Intestine to the Anus

After a few hours in the stomach, plus three to six hours in the small intestine, and about sixteen hours in the large intestine, the
digestion process enters step four, which is the elimination of indigestible food as feces. Feces contain indigestible food and gut
bacteria (almost 50 percent of content). It is stored in the rectum until it is expelled through the anus via defecation.

Video : The Stages of Digestion

This video reviews the sequence of events during food digestion.

The Stages of Digestion

Key Takeaways
The breakdown of complex macromolecules in foods to simple absorbable components is accomplished by the digestive
system. These components are processed by cells throughout the body into energy or are used as building blocks.
The digestive system is composed of the mouth, pharynx, esophagus, stomach, small intestine, large intestine (or colon),
rectum, and anus. There are four steps in the digestion process: ingestion, the mechanical and chemical breakdown of food,
nutrient absorption, and elimination of indigestible food.
The mechanical breakdown of food occurs via muscular contractions called peristalsis and segmentation. Enzymes secreted by
the salivary glands, stomach, pancreas, and small intestine accomplish the chemical breakdown of food. Additionally, bile
emulsifies fats.

[Link] [Link]
Discussion Starter
1. Decide whether you want to consume pre- and probiotic foods to benefit your health. Visit the websites below to help in your
decision-making process. Defend your decision scientifically.
[Link]
[Link]

3.4.1: Digestion and Absorption is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

[Link] [Link]
3.5: The Cardiovascular System
The cardiovascular system is one of the eleven organ systems of the human body. Its main function is to transport nutrients to cells
and wastes from cells (Figure ).

Figure : The Cardiovascular system. “Simplified diagram of the human Circulatory

system in anterior view” by Mariana Ruiz / Public Domain
This system consists of the heart, blood, and blood vessels (Figure ). The heart pumps the blood, and the blood is the
transportation fluid. The transportation route to all tissues, a highly intricate blood-vessel network, comprises arteries, veins, and
capillaries. Nutrients absorbed in the small intestine travel mainly to the liver through the hepatic portal vein. From the liver,
nutrients travel upward through the inferior vena cava blood vessel to the heart. The heart forcefully pumps the nutrient-rich blood
first to the lungs to pick up some oxygen and then to all other cells in the body. Arteries become smaller and smaller on their way to
cells, so that by the time blood reaches a cell, the artery’s diameter is extremely small and the vessel is now called a capillary. The
reduced diameter of the blood vessel substantially slows the speed of blood flow. This dramatic reduction in blood flow gives cells
time to harvest the nutrients in blood and exchange metabolic wastes.

3.5.1 [Link]
 Figure : The Blood Flow in the
Cardiovascular System. “Blood Flow Through the Heart” by OpenStax College / CC BY 3.0

Blood’s Function in the Body and in Metabolism Support

You know you cannot live without blood, and that your heart pumps your blood over a vast network of veins and arteries within
your body, carrying oxygen to your cells. However, beyond these basic facts, what do you know about your blood?
Blood transports absorbed nutrients to cells and waste products from cells. It supports cellular metabolism by transporting
synthesized macromolecules from one cell type to another and carrying waste products away from cells. Additionally, it transports
molecules, such as hormones, allowing for communication between organs. The volume of blood coursing throughout an adult
human body is about 5 liters (1.3 US gallons) and accounts for approximately 8 percent of human body weight.

What Makes Up Blood and How Do These Substances Support Blood Function?
Blood is about 78 percent water and 22 percent solids by volume. The liquid part of blood is called plasma and it is mostly water
(95 percent), but also contains proteins, ions, glucose, lipids, vitamins, minerals, waste products, gases, enzymes, and hormones.
We have learned that the protein albumin is found in high concentrations in the blood. Albumin helps maintain fluid balance
between blood and tissues, as well as helping to maintain a constant blood pH. We have also learned that the water component of
blood is essential for its actions as a transport vehicle, and that the electrolytes carried in blood help to maintain fluid balance and a
constant pH. Furthermore, the high water content of blood helps maintain body temperature, and the constant flow of blood
distributes heat throughout the body. Blood is exceptionally good at temperature control, so much so that the many small blood
vessels in your nose are capable of warming frigid air to body temperature before it reaches the lungs.
The cellular components of blood include red blood cells, white blood cells, and platelets. Red blood cells are the most numerous
of the components. Each drop of blood contains millions of them. Red blood cells are red because they each contain approximately
270 million hemoglobin proteins, which contain the mineral iron, which turns red when bound to oxygen. The most vital duty of
red blood cells is to transport oxygen from the lungs to all cells in the body so that cells can utilize oxygen to produce energy via
aerobic metabolism. The white blood cells that circulate in blood are part of the immune system, and they survey the entire body
looking for foreign invaders to destroy. They make up about 1 percent of blood volume. Platelets are fragments of cells that are
always circulating in the blood in case of an emergency. When blood vessels are injured, platelets rush to the site of injury to plug
the wound. Blood is under a constant state of renewal and is synthesized from stem cells residing in bone marrow. Red blood cells
live for about 120 days, white blood cells live anywhere from eighteen hours to one year, or even longer, and platelets have a
lifespan of about ten days.

3.5.2 [Link]
 Figure : Cardiovascular Transportation of Nutrients. The
cardiovascular system transports nutrients to all cells and carries wastes out.

Nutrients In
Once absorbed from the small intestine, all nutrients require transport to cells in need of their support. Additionally, molecules
manufactured in other cells sometimes require delivery to other organ systems. Blood is the conduit and blood vessels are the
highway that support nutrient and molecule transport to all cells. Water-soluble molecules, such as some vitamins, minerals, sugars,
and many proteins, move independently in blood. Fat-soluble vitamins, triglycerides, cholesterol, and other lipids are packaged into
lipoproteins that allow for transport in the watery milieu of blood. Many proteins, drugs, and hormones are dependent on transport
carriers, primarily by the plasma protein albumin. In addition to transporting all of these molecules, blood transfers oxygen taken in
by the lungs to all cells in the body. As discussed, the iron-containing hemoglobin molecule in red blood cells serves as the oxygen
carrier.

Wastes Out
In the metabolism of macronutrients to energy, cells produce the waste products carbon dioxide and water. As blood travels through
smaller and smaller vessels, the rate of blood flow is dramatically reduced, allowing for efficient exchange of nutrients and oxygen
for cellular waste products through tiny capillaries. The kidneys remove any excess water from the blood, and blood delivers the
carbon dioxide to the lungs where it is exhaled. Also, the liver produces the waste product urea from the breakdown of amino acids
and detoxifies many harmful substances, all of which require transport in the blood to the kidneys for excretion.

All for One, One for All

The eleven organ systems in the body completely depend on each other for continued survival as a complex organism. Blood
allows for transport of nutrients, wastes, water, and heat, and is also a conduit of communication between organ systems. Blood’s
importance to the rest of the body is aptly presented in its role in glucose delivery, especially to the brain. The brain metabolizes, on
average, 6 grams of glucose per hour. In order to avert confusion, coma, and death, glucose must be readily available to the brain at
all times. To accomplish this task, cells in the pancreas sense glucose levels in the blood. If glucose levels are low, the hormone
glucagon is released into the blood and is transported to the liver where it communicates the signal to ramp-up glycogen breakdown
and glucose synthesis. The liver does just that, and glucose is released into the blood, which transports it to the brain. Concurrently,
blood transports oxygen to support the metabolism of glucose to provide energy in the brain. Healthy blood conducts its duties
rapidly, avoiding hypoglycemic coma and death. This is just one example of the body’s survival mechanisms exemplifying life’s
mantra “All for one, one for all.”

3.5.3 [Link]
What Makes Blood Healthy?
Maintaining healthy blood, including its continuous renewal, is essential to support its vast array of vital functions. Blood is
healthy when it contains the appropriate amount of water and cellular components and proper concentrations of dissolved
substances, such as albumin and electrolytes. As with all other tissues, blood needs macro- and micronutrients to optimally
function. In the bone marrow, where blood cells are made, amino acids are required to build the massive amount of hemoglobin
packed within every red blood cell, along with all other enzymes and cellular organelles contained in each blood cell. Red blood
cells, similar to the brain, use only glucose as fuel, and it must be in constant supply to support red-blood-cell metabolism. As with
all other cells, the cells in the blood are surrounded by a plasma membrane, which is composed of mainly lipids. Blood health is
also acutely sensitive to deficiencies in some vitamins and minerals more than others.

What Can Blood Tests Tell You About Your Health?

Since blood is the conduit of metabolic products and wastes, measuring the components of blood, and particular substances in
blood, can reveal not only the health of blood, but also the health of other organ systems. In standard blood tests performed during
an annual physical, the typical blood tests conducted can tell your physician about the functioning of a particular organ or about
disease risk.

Figure : Blood Tests. Blood tests are helpful tools in diagnosing

disease and provide much information on overall health. Image by Thirteen of Clubs / CC BY-SA
A biomarker is defined as a measurable molecule or trait that is connected with a specific disease or health condition. The
concentrations of biomarkers in blood are indicative of disease risk. Some biomarkers are cholesterol, triglycerides, glucose, and
prostate-specific antigen. The results of a blood test give the concentrations of substances in a person’s blood and display the
normal ranges for a certain population group. Many factors, such as physical activity level, diet, alcohol intake, and medicine
intake can influence a person’s blood-test levels and cause them to fall outside the normal range, so results of blood tests outside
the “normal” range are not always indicative of health problems. The assessment of multiple blood parameters aids in the diagnosis
of disease risk and is indicative of overall health status. See Table for a partial list of substances measured in a typical blood
test. This table notes only a few of the things that their levels tell us about health.
Table : Blood Tests

3.5.4 [Link]
 Substance Measured Indicates

Red-blood-cell count Oxygen-carrying capacity

Hematocrit (red-blood-cell volume) Anemia risk

White-blood-cell count Presence of infection

Platelet count Bleeding disorders, atherosclerosis risk

pH Metabolic, kidney, respiratory abnormalities

Albumin Liver, kidney, and Crohn’s disease, dehydration, protein deficiency

Bilirubin Liver-function abnormality

Oxygen/Carbon Dioxide Respiratory or metabolic abnormality

Hemoglobin Oxygen-carrying capacity

Iron Anemia risk

Magnesium Magnesium deficiency

Electrolytes (calcium, chloride, magnesium, potassium) Many illnesses (kidney, metabolic, etc.)

Cholesterol Cardiovascular disease risk

Triglycerides Cardiovascular disease risk

Glucose Diabetes risk

Hormones Many illnesses (diabetes, reproductive abnormalities)

National Heart Lung and Blood Institute. Types of Blood Tests.[1]

1. National Heart Lung and Blood Institute (2012, January 6). Blood Tests. [Link]
topics/topics/bdt/[Link]↵

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LibreTexts platform.
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3.5.5 [Link]
3.6: Central Nervous System
The human brain (which weighs only about 3 pounds, or 1,300 kilograms) is estimated to contain over one hundred billion neurons.
Neurons form the core of the central nervous system, which consists of the brain, spinal cord, and other nerve bundles in the body
(Figure ). The main function of the central nervous system is to sense changes in the external environment and create a
reaction to them. For instance, if your finger comes into contact with a thorn on a rose bush, a sensory neuron transmits a signal
from your finger up through the spinal cord and into the brain. Another neuron in the brain sends a signal that travels back to the
muscles in your hand and stimulates muscles to contract and you jerk your finger away. All of this happens within a tenth of a
second. All nerve impulses travel by the movement of charged sodium, potassium, calcium, and chloride atoms. Nerves
communicate with each other via chemicals built from amino acids called neurotransmitters. Eating adequate protein from a variety
of sources will ensure the body gets all of the different amino acids that are important for central nervous system function.

Figure : The Central Nervous System. Nervous System” by William Crochot / CC BY-
SA 4.0
The brain’s main fuel is glucose and only in extreme starvation will it use anything else. For acute mental alertness and clear
thinking, glucose must be systematically delivered to the brain. This does not mean that sucking down a can of sugary soda before
your next exam is a good thing. Just as too much glucose is bad for other organs, such as the kidneys and pancreas, it also produces
negative effects upon the brain. Excessive glucose levels in the blood can cause a loss of cognitive function, and chronically high
blood-glucose levels can damage brain cells. The brain’s cognitive functions include language processing, learning, perceiving, and
thinking. Recent scientific studies demonstrate that having continuously high blood-glucose levels substantially elevates the risk
for developing Alzheimer’s disease, which is the greatest cause of age-related cognitive decline.
The good news is that much research is directed toward determining the best diets and foods that slow cognitive decline and
maximize brain health. A study in the June 2010 issue of the Archives of Neurology reports that people over age 65 who adhered to
diets that consisted of higher intakes of nuts, fish, poultry, tomatoes, cruciferous vegetables, fruits, salad dressing, and dark green,
and leafy vegetables, as well as a lower intake of high-fat dairy products, red meat, organ meat, and butter, had a much reduced risk
for Alzheimer’s disease.[1]

3.6.1 [Link]
Other scientific studies provide supporting evidence that foods rich in omega-3 fatty acids and/or antioxidants provide the brain
with protection against Alzheimer’s disease. One potential “brain food” is the blueberry. The protective effects of blueberries upon
the brain are linked to their high content of anthocyanins, which are potent antioxidants and reduce inflammation. A small study
published in the April 2010 issue of the Journal of Agricultural and Food Chemistry found that elderly people who consumed
blueberry juice every day for twelve weeks had improved learning and memorization skills in comparison to other subjects given a
placebo drink.[2]
However, it is important to keep in mind that this was a short-term study. Blueberries also are high in manganese, and high intake
of manganese over time is known to have neurotoxic effects. Variety in the diet is perhaps the most important concept in applied
nutrition. More clinical trials are evaluating the effects of blueberries and other foods that benefit the brain and preserve its function
as we age.
1. Gu Y, Nieves JW, et al. (2010). Food Combination and Alzheimer Disease Risk: A Protective Diet. Archives of Neurology,67(6),
699–706. [Link]
2. Krikorian R, Shidler MD, et al. (2010). Blueberry Supplementation Improves Memory in Older Adults. Journal of Agricultural
and Food Chemistry, 58(7). [Link]

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platform.
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3.6.2 [Link]
3.7: The Respiratory System
A typical human cannot survive without breathing for more than 3 minutes, and even if you wanted to hold your breath longer, your
autonomic nervous system would take control. This is because cells need to maintain oxidative metabolism for energy production
that continuously regenerates adenosine triphosphate (ATP). For oxidative phosphorylation to occur, oxygen is used as a reactant
and carbon dioxide is released as a waste product. You may be surprised to learn that although oxygen is a critical need for cells, it
is actually the accumulation of carbon dioxide that primarily drives your need to breathe. Carbon dioxide is exhaled and oxygen is
inhaled through the respiratory system, which includes muscles to move air into and out of the lungs, passageways through which
air moves, and microscopic gas exchange surfaces covered by capillaries. The cardiovascular system transports gases from the
lungs to tissues throughout the body and vice versa. A variety of diseases can affect the respiratory system, such as asthma,
emphysema, chronic obstructive pulmonary disorder (COPD), and lung cancer. All of these conditions affect the gas exchange
process and result in labored breathing and other difficulties.
The major organs of the respiratory system function primarily to provide oxygen to body tissues for cellular respiration, remove the
waste product carbon dioxide, and help to maintain acid-base balance. Portions of the respiratory system are also used for non-vital
functions, such as sensing odors, producing speech, and for straining, such as during childbirth or coughing.

Figure : Major Respiratory Structures. Major organs of

the respiratory system
The major respiratory structures span the nasal cavity to the diaphragm. Functionally, the respiratory system can be divided into a
conducting zone and a respiratory zone. The conducting zone of the respiratory system includes the organs and structures not
directly involved in gas exchange (trachea and bronchi). The gas exchange occurs in the respiratory zone.

Conducting Zone
The major functions of the conducting zone are to provide a route for incoming and outgoing air, remove debris and pathogens
from the incoming air, and warm and humidify the incoming air. Several structures within the conducting zone perform other
functions as well. The epithelium of the nasal passages, for example, is essential to sensing odors, and the bronchial epithelium that
lines the lungs can metabolize some airborne carcinogens. The conducting zone includes the nose and its adjacent structures, the
pharynx, the larynx, the trachea, and the bronchi.

Respiratory Zone
In contrast to the conducting zone, the respiratory zone includes structures that are directly involved in gas exchange. The
respiratory zone begins where the terminal bronchioles join a respiratory bronchiole, the smallest type of bronchiole (Figure ),
which then leads to an alveolar duct, opening into a cluster of alveoli.

3.7.1 [Link]
 Figure : Respiratory Zone. Bronchioles lead
to alveolar sacs in the respiratory zone, where gas exchange occurs.

Alveoli
An alveolar duct is a tube composed of smooth muscle and connective tissue, which opens into a cluster of alveoli. An alveolus is
one of the many small, grape-like sacs that are attached to the alveolar ducts.
An alveolar sac is a cluster of many individual alveoli that are responsible for gas exchange. An alveolus is approximately 200 μm
in diameter with elastic walls that allow the alveolus to stretch during air intake, which greatly increases the surface area available
for gas exchange. Alveoli are connected to their neighbors by alveolar pores, which help maintain equal air pressure throughout the
alveoli and lung.

Figure : Location of Respiratory System. “Human Respiratory

System” by United States National Institute of Health: National Heart, Lung and Blood Institute / Public Domain
Figure shows the location of the respiratory structures in the body. Figure B is an enlarged view of the airways, alveoli (air
sacs), and capillaries (tiny blood vessels). Figure C is a close-up view of gas exchange between the capillaries and alveoli. is
carbon dioxide, and is oxygen.
A major organ of the respiratory system, each lung houses structures of both the conducting and respiratory zones. The main
function of the lungs is to perform the exchange of oxygen and carbon dioxide with air from the atmosphere. To this end, the lungs
exchange respiratory gases across a very large epithelial surface area—about 70 square meters—that is highly permeable to gases.

3.7.2 [Link]
Gross Anatomy of the Lungs
The lungs are pyramid-shaped, paired organs that are connected to the trachea by the right and left bronchi (Figure ); below the
lungs is the diaphragm, a flat, dome-shaped muscle located at the base of the lungs and thoracic cavity.

Figure : Basic
Anatomy of the Lungs. Bronchioles lead to alveolar sacs in the respiratory zone, where gas exchange occurs.
Each lung is composed of smaller units called lobes. Fissures separate these lobes from each other. The right lung consists of three
lobes: the superior, middle, and inferior lobes. The left lung consists of two lobes: the superior and inferior lobes.

Blood Supply
The major function of the lungs is to perform gas exchange, which requires blood flowing through the lung tissues (the pulmonary
circulation). This blood supply contains deoxygenated blood and travels to the lungs where erythrocytes, also known as red blood
cells, pick up oxygen to be transported to tissues throughout the body. The pulmonary artery carries deoxygenated blood to the
lungs. The pulmonary artery branches multiple times as it follows the bronchi, and each branch becomes progressively smaller in
diameter down to the tiny capillaries where the alveoli release carbon dioxide from blood into the lungs to be exhaled and take up
oxygen from inhaled air to oxygenate the blood. Once the blood is oxygenated, it drains from the alveoli by way of multiple
pulmonary veins that exit the lungs to carry oxygen to the rest of the body.

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3.7.3 [Link]
3.8: The Endocrine System
The functions of the endocrine system are intricately connected to the body’s nutrition. This organ system is responsible for
regulating appetite, nutrient absorption, nutrient storage, and nutrient usage, in addition to other functions, such as reproduction.
The glands in the endocrine system are the pituitary, thyroid, parathyroid, adrenals, thymus, pineal, pancreas, ovaries, and testes
(Figure . The glands secrete hormones, which are biological molecules that regulate cellular processes in other target tissues,
so they require transportation by the circulatory system. Adequate nutrition is critical for the functioning of all the glands in the
endocrine system. A protein deficiency impairs gonadal-hormone release, preventing reproduction. Athletic teenage girls with very
little body fat often do not menstruate. Children who are malnourished usually do not produce enough growth hormone and fail to
reach normal height for their age group. Probably the most popularized connection between nutrition and the functions of the
endocrine system is that unhealthy dietary patterns are linked to obesity and the development of Type 2 diabetes. The Centers for
Disease Control and Prevention (CDC) estimates that twenty-six million Americans have Type 2 diabetes as of 2011. This is 8.3
percent of the US population. Counties with the highest incidence of obesity also have the highest incidence of Type 2 diabetes. To
see how the rise in obesity in this country is paralleled by the rise in Type 2 diabetes, review this report by the CDC.
[Link]

Figure : The Endocrine System. “Major Endocrine Glands” by National

Cancer Institute / Public Domain
What is the causal relationship between overnutrition and Type 2 diabetes? The prevailing theory is that the overconsumption of
high-fat and high-sugar foods causes changes in muscle, fat, and liver cells that leads to a diminished response from the pancreatic
hormone insulin. These cells are called “insulin-resistant.” Insulin is released after a meal and instructs the liver and other tissues to
take up glucose and fatty acids that are circulating in the blood. When cells are resistant to insulin they do not take up enough
glucose and fatty acids, so glucose and fatty acids remain at high concentrations in the blood. The chronic elevation of glucose and
fatty acids in the blood also causes damage to other tissues over time, so that people who have Type 2 diabetes are at increased risk
for cardiovascular disease, kidney disease, nerve damage, and eye disease.

 Career Connection

Do your part to slow the rising tide of obesity and Type 2 diabetes in this country. On the individual level, improve your own
family’s diet; at the local community level, support the development of more nutritious school lunch programs; and at the
national level, support your nation’s nutrition goals. Visit the CDC Diabetes Public Health Resource website at
[Link]/diabetes/. It provides information on education resources, projects, and programs, and spotlights news on
diabetes. For helpful information on obesity, visit [Link] The CDC also has workplace web-based
resources with the mission of designing work sites that prevent obesity. See
[Link] or more details.

3.8.1 [Link]
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Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts
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source: [Link]

3.8.2 [Link]
3.9: The Urinary System
The urinary system has roles you may be well aware of: cleansing the blood and ridding the body of wastes probably come to mind.
However, there are additional, equally important functions played by the system. Take for example, regulation of pH, a function
shared with the lungs and the buffers in the blood. Additionally, the regulation of blood pressure is a role shared with the heart and
blood vessels. What about regulating the concentration of solutes in the blood? Did you know that the kidney is important in
determining the concentration of red blood cells? Eighty-five percent of the erythropoietin (EPO) produced to stimulate red blood
cell production is produced in the kidneys. The kidneys also perform the final synthesis step of vitamin D production, converting
calcidiol to calcitriol, the active form of vitamin D.
If the kidneys fail, these functions are compromised or lost altogether, with devastating effects on homeostasis. The affected
individual might experience weakness, lethargy, shortness of breath, anemia, widespread edema (swelling), metabolic acidosis,
rising potassium levels, heart arrhythmias, and more. Each of these functions is vital to your well-being and survival. The urinary
system, controlled by the nervous system, also stores urine until a convenient time for disposal and then provides the anatomical
structures to transport this waste liquid to the outside of the body. Failure of nervous control or the anatomical structures leading to
a loss of control of urination results in a condition called incontinence.
Characteristics of the urine change, depending on influences such as water intake, exercise, environmental temperature, nutrient
intake, and other factors . Some of the characteristics such as color and odor are rough descriptors of your state of hydration (Figure
). For example, if you exercise or work outside, and sweat a great deal, your urine will turn darker and produce a slight odor,
even if you drink plenty of water. Athletes are often advised to consume water until their urine is clear. This is good advice;
however, it takes time for the kidneys to process body fluids and store it in the bladder. Another way of looking at this is that the
quality of the urine produced is an average over the time it takes to make that urine. Producing clear urine may take only a few
minutes if you are drinking a lot of water or several hours if you are working outside and not drinking much.

Figure : Urine Color. “Urine Color” by OpenStax College / CC BY 3.0

Urine volume varies considerably. The normal range is one to two liters per day. The kidneys must produce a minimum urine
volume of about 500 mL/day to rid the body of wastes. Output below this level may be caused by severe dehydration or renal
disease and is termed oliguria. The virtual absence of urine production is termed anuria. Excessive urine production is polyuria,
which may occur in diabetes mellitus when blood glucose levels exceed the filtration capacity of the kidneys and glucose appears
in the urine. The osmotic nature of glucose attracts water, leading to increased water loss in the urine.

3.9.1 [Link]
 Figure : Urinary System Location. “Illu Urinary System” by Thstehle / Public Domain
Urine is a fluid of variable composition that requires specialized structures to remove it from the body safely and efficiently. Blood
is filtered, and the filtrate is transformed into urine at a relatively constant rate throughout the day. This processed liquid is stored
until a convenient time for excretion. All structures involved in the transport and storage of the urine are large enough to be visible
to the naked eye. This transport and storage system not only stores the waste, but it protects the tissues from damage due to the
wide range of pH and osmolarity of the urine, prevents infection by foreign organisms, and for the male, provides reproductive
functions. The urinary bladder collects urine from both ureters (Figure ).

Figure : The Bladder. “The Bladder” by

OpenStax College / CC BY 3.0
The kidneys lie on either side of the spine in the retroperitoneal space behind the main body cavity that contains the intestines. The
kidneys are well protected by muscle, fat, and the lower ribs. They are roughly the size of your fist, and the male kidney is typically
a bit larger than the female kidney. The kidneys are well vascularized, receiving about 25 percent of the cardiac output at rest.

3.9.2 [Link]
 Figure : The Kidneys. “Kidney Position in
Abdomen” by OpenStax College / CC BY 3.0
The kidneys (as viewed from the back of the body) are slightly protected by the ribs and are surrounded by fat for protection (not
shown).
The effects of failure of parts of the urinary system may range from inconvenient (incontinence) to fatal (loss of filtration and many
other functions). The kidneys catalyze the final reaction in the synthesis of active vitamin D that in turn helps regulate . The
kidney hormone EPO stimulates erythrocyte development and promotes adequate transport. The kidneys help regulate blood
pressure through Na+ and water retention and loss. The kidneys work with the adrenal cortex, lungs, and liver in the renin–
angiotensin–aldosterone system to regulate blood pressure. They regulate osmolarity of the blood by regulating both solutes and
water. Three electrolytes are more closely regulated than others: , , and . The kidneys share pH regulation with the
lungs and plasma buffers, so that proteins can preserve their three-dimensional conformation and thus their function.

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3.9.3 [Link]
3.10: The Muscular System
The muscular system allows the body to move voluntarily, but it also controls involuntary movements of other organ systems such
as heartbeat in the circulatory system and peristaltic waves in the digestive system. It consists of over six hundred skeletal muscles,
as well as the heart muscle, the smooth muscles that surround your entire alimentary canal, and all your arterial blood vessels
(Figure ). Muscle contraction relies on energy delivery to the muscle. Each movement uses up cellular energy, and without an
adequate energy supply, muscle function suffers. Muscle, like the liver, can store the energy from glucose in the large polymeric
molecule glycogen. But unlike the liver, muscles use up all of their own stored energy and do not export it to other organs in the
body. Muscle is not as susceptible to low levels of blood glucose as the brain because it will readily use alternate fuels such as fatty
acids and protein to produce cellular energy.

Figure : The Muscular System in the

Human Body. “Muscle Types” by BruceBlaus / CC BY-SA 4.0

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3.10.1 [Link]
3.11: The Skeletal System
Bone Structure and Function
Your bones are stronger than reinforced concrete. Bone tissue is a composite of fibrous strands of collagen (a type of protein) that
resemble the steel rebar in concrete and a hardened mineralized matrix that contains large amounts of calcium, just like concrete.
But this is where the similarities end. Bone outperforms reinforced concrete by several orders of magnitude in compression and
tension strength tests. Why? The microarchitecture of bone is complex and built to withstand extreme forces. Moreover, bone is a
living tissue that is continuously breaking down and forming new bone to adapt to mechanical stresses.

Why Is the Skeletal System Important?

The human skeleton consists of 206 bones and other connective tissues called ligaments, tendons, and cartilage (Figure .
Ligaments connect bones to other bones, tendons connect bones to muscles, and cartilage provides bones with more flexibility and
acts as a cushion in the joints between bones. The skeleton’s many bones and connective tissues allow for multiple types of
movement such as typing and running. The skeleton provides structural support and protection for all the other organ systems in the
body. The skull, or cranium, is like a helmet and protects the eyes, ears, and brain. The ribs form a cage that surrounds and protects
the lungs and heart. In addition to aiding in movement, protecting organs, and providing structural support, red and white blood
cells and platelets are synthesized in bone marrow. Another vital function of bones is that they act as a storage depot for minerals
such as calcium, phosphorous, and magnesium. Although bone tissue may look inactive at first glance, at the microscopic level you
will find that bones are continuously breaking down and reforming. Bones also contain a complex network of canals, blood vessels,
and nerves that allow for nutrient transport and communication with other organ systems.

3.11.1 [Link]
 Figure
: Human Skeletal Structure. “Axial Skeleton” by Openstax College / CC BY 3.0
The human skeleton contains 206 bones. It is divided into two main parts, the axial and appendicular.

Bone Anatomy and Structure

To optimize bone health through nutrition, it is important to understand bone anatomy. The skeleton is composed of two main parts,
the axial and the appendicular parts. The axial skeleton consists of the skull, vertebral column, and rib cage, and is composed of
eighty bones. The appendicular skeleton consists of the shoulder girdle, pelvic girdle, and upper and lower extremities, and is
composed of 126 bones. Bones are also categorized by size and shape. There are four types of bone: long bones, short bones, flat
bones, and irregular bones. The longest bone in your body is the femur (thigh bone), which extends from your hip to your knee. It
is a long bone and functions to support your weight as you stand, walk, or run. Your wrist is composed of eight irregular-shaped
bones, which allow for the intricate movements of your hands. Your twelve ribs on each side of your body are curved flat bones
that protect your heart and lungs. Thus, the bones’ different sizes and shapes allow for their different functions.
Bones are composed of approximately 65 percent inorganic material known as mineralized matrix. This mineralized matrix consists
of mostly crystallized hydroxyapatite. The bone’s hard crystal matrix of bone tissue gives it its rigid structure. The other 35 percent

3.11.2 [Link]
of bone is organic material, most of which is the fibrous protein collagen. The collagen fibers are networked throughout bone tissue
and provide it with flexibility and strength. The bones’ inorganic and organic materials are structured into two different tissue types.
There is spongy bone, also called trabecular or cancellous bone, and compact bone, also called cortical bone (Figure ). The
two tissue types differ in their microarchitecture and porosity. Trabecular bone is 50 to 90 percent porous and appears as a lattice-
like structure under the microscope. It is found at the ends of long bones, in the cores of vertebrae, and in the pelvis. Trabecular
bone tissue makes up about 20 percent of the adult skeleton. The more dense cortical bone is about 10 percent porous and it looks
like many concentric circles, similar to the rings in a tree trunk, sandwiched together (Figure ). Cortical bone tissue makes up
approximately 80 percent of the adult skeleton. It surrounds all trabecular tissue and is the only bone tissue in the shafts of long
bones.

Figure : The Arrangement of Bone Tissues.

Image by Gtirouflet / CC BY-SA 3.0
The two basic tissue types of bones are trabecular and cortical. Figure shows normal (left) and degraded (right) trabecular
(spongy) bone.

3.11.3 [Link]
 Figure : Cortical (Compact) Bone.
“Compact Bone with osteons” by Lord of Konrad / CC0
Bone tissue is arranged in an organized manner. A thin membrane, called the periosteum, surrounds the bone. It contains connective
tissue with many blood vessels and nerves. Lying below the periosteum is the cortical bone. In some bones, the cortical bone
surrounds the less-dense trabecular bone and the bone marrow lies within the trabecular bone, but not all bones contain trabecular
tissue or marrow.

Bone Tissues and Cells, Modeling and Remodeling

Bone tissue contains many different cell types that constantly resize and reshape bones throughout growth and adulthood. Bone
tissue cells include osteoprogenitor cells, osteoblasts, osteoclasts, and osteocytes. The osteoprogenitor cells are cells that have not
matured yet. Once they are stimulated, some will become osteoblasts, the bone builders, and others will become osteoclasts, the
cells that break bone down. Osteocytes are the most abundant cells in bone tissue. Osteocytes are star-shaped cells that are
networked throughout the bone via their long cytoplasmic arms that allow for the exchange of nutrients and other factors from
bones to the blood and lymph.

Bone Modeling and Remodeling

During infancy, childhood, and adolescence, bones are continuously growing and changing shape through two processes called
growth (ossification) and modeling. In fact, in the first year of life, almost 100 percent of the bone tissue in the skeleton is replaced.
In the process of modeling, bone tissue is dismantled at one site and built up at a different site. In adulthood, our bones stop
growing and modeling, but continue to go through a process of bone remodeling. In the process of remodeling, bone tissue is
degraded and built up at the same location. About 10 percent of bone tissue is remodeled each year in adults. Bones adapt their
structure to the forces acting upon them, even in adulthood. This phenomenon is called Wolff’s law, which states that bones will
develop a structure that is best able to resist the forces acting upon them. This is why exercising, especially when it involves
weight-bearing activities, increases bone strength.
The first step in bone remodeling is osteocyte activation. Osteocytes detect changes in mechanical forces, calcium homeostasis, or
hormone levels. In the second step, osteoclasts are recruited to the site of the degradation. Osteoclasts are large cells with a highly
irregular ruffled membrane. These cells fuse tightly to the bone and secrete hydrogen ions, which acidify the local environment and
dissolve the minerals in the bone tissue matrix. This process is called bone resorption and resembles pit excavation. Our bodies
excavate pits in our bone tissue because bones act as storehouses for calcium and other minerals. Bones supply these minerals to
other body tissues as the demand arises. Bone tissue also remodels when it breaks so that it can repair itself. Moreover, if you

3.11.4 [Link]
decide to train to run a marathon your bones will restructure themselves by remodeling to be better able to sustain the forces of
their new function.
After a certain amount of bone is excavated, the osteoclasts begin to die and bone resorption stops. In the third step of bone
remodeling, the site is prepared for building. In this stage, sugars and proteins accumulate along the bone’s surface, forming a
cement line which acts to form a strong bond between the old bone and the new bone that will be made. These first three steps take
approximately two to three weeks to complete. In the last step of bone remodeling, osteoblasts lay down new osteoid tissue that
fills up the cavities that were excavated during the resorption process. Osteoid is bone matrix tissue that is composed of proteins
such as collagen and is not mineralized yet. To make collagen, vitamin C is required. A symptom of vitamin C deficiency (known
as scurvy) is bone pain, which is caused by diminished bone remodeling. After the osteoid tissue is built up, the bone tissue begins
to mineralize. The last step of bone remodeling continues for months, and for a much longer time afterward the mineralized bone is
continuously packed in a more dense fashion.
Thus, we can say that bone is a living tissue that continually adapts itself to mechanical stress through the process of remodeling.
For bone tissue to remodel certain nutrients such as calcium, phosphorus, magnesium, fluoride, vitamin D, and vitamin K are
required.

Bone Mineral Density Is an Indicator of Bone Health

Bone mineral density (BMD) is a measurement of the amount of calcified tissue in grams per centimeter squared of bone tissue.
BMD can be thought of as the total amount of bone mass in a defined area. When BMD is high, bone strength will be great. Similar
to measuring blood pressure to predict the risk of stroke, a BMD measurement can help predict the risk of bone fracture. The most
common tool used to measure BMD is called dual energy X-ray absorptiometry (DEXA). During this procedure, a person lies on
their back and a DEXA scanner passes two X-ray beams through their body. The amount of X-ray energy that passes through the
bone is measured for both beams. The total amount of the X-ray energy that passes through a person varies depending on their bone
thickness. Using this information and a defined area of bone, the amount of calcified tissue in grams per unit area (cm2) is
calculated. Most often the DEXA scan focuses on measuring BMD in the hip and the spine. These measurements are then used as
indicators of overall bone strength and health. DEXA is the cheapest and most accurate way to measure BMD. It also uses the
lowest dose of radiation. Other methods of measuring BMD include quantitative computed tomography (QCT) and radiographic
absorptiometry. People at risk for developing bone disease are advised to have a DEXA scan. We will discuss the many risk factors
linked to an increased incidence of osteoporosis and the steps a person can take to prevent the disease from developing.

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3.11.5 [Link]
3.12: The Immune System
The immune system comprises several types of white blood cells that circulate in the blood and lymph. Their jobs are to seek,
recruit, attack, and destroy foreign invaders, such as bacteria and viruses. Other less realized components of the immune system are
the skin (which acts as a barricade), mucus (which traps and entangles microorganisms), and even the bacteria in the large intestine
(which prevent the colonization of bad bacteria in the gut). Immune system functions are completely dependent on dietary
nutrients. In fact, malnutrition is the leading cause of immune-system deficiency worldwide. When immune system functions are
inadequate there is a marked increase in the chance of getting an infection. Children in many poor, developing countries have
protein- and/or energy-deficient diets that are causative of two different syndromes, kwashiorkor and marasmus. These children
often die from infections that their bodies would normally have fought off, but because their protein and/or energy intake is so low,
the immune system cannot perform its functions.
Other nutrients, such as iron, zinc, selenium, copper, folate, and vitamins A, B6, C, D, and E, all provide benefits to immune system
function. Deficiencies in these nutrients can cause an increased risk for infection and death. Zinc deficiency results in suppression
of the immune system’s barrier functions by damaging skin cells; it is also associated with a decrease in the number of circulating
white blood cells. A review of several studies in the journal Pediatrics concluded that zinc supplements administered to children
under age five for longer than three months significantly reduces the incidence and severity of diarrhea and respiratory illnesses.[1]
Zinc supplementation also has been found to be therapeutically beneficial for the treatment of leprosy, tuberculosis, pneumonia,
and the common cold. Equally important to remember is that multiple studies show that it is best to obtain your minerals and
vitamins from eating a variety of healthy foods.
Just as undernutrition compromises immune system health, so does overnutrition. People who are obese are at increased risk for
developing immune system disorders such as asthma, rheumatoid arthritis, and some cancers. Both the quality and quantity of fat
affect immune system function. High intakes of saturated and trans fats negatively affect the immune system, whereas increasing
your intake of omega-3 fatty acids, found in salmon and other oily fish, decreases inflammatory responses. High intakes of omega-
3 fatty acids are linked to a reduction in the risk of developing certain autoimmune disorders, such as rheumatoid arthritis, and are
used as part of a comprehensive treatment for rheumatoid arthritis.
1. Aggarwal R, Sentz J, Miller MA. (2007). Role of Zinc Administration in Prevention of Childhood Diarrhea and Respiratory
Illnesses: A Meta-Analysis. Pediatrics, 119(6), 1120–30. [Link]

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3.12.1 [Link]
3.13: Indicators of Health- Body Mass Index, Body Fat Content, and Fat Distribution
Although the terms overweight and obese are often used interchangeably and considered as gradations of the same thing, they
denote different things. The major physical factors contributing to body weight are water weight, muscle tissue mass, bone tissue
mass, and fat tissue mass. Overweight refers to having more weight than normal for a particular height and may be the result of
water weight, muscle weight, or fat mass. Obese refers specifically to having excess body fat. In most cases people who are
overweight also have excessive body fat and therefore body weight is an indicator of obesity in much of the population.
The “ideal” healthy body weight for a particular person is dependent on many things, such as frame size, sex, muscle mass, bone
density, age, and height. The perception of the “ideal” body weight is additionally dependent on cultural factors and the mainstream
societal advertisement of beauty.
To standardize the “ideal” body weight and relate it to health, scientists have devised mathematical formulas to better define a
healthy weight (Figure ). These mathematically derived measurements are used by health professionals to correlate disease
risk with populations of people and at the individual level. A clinician will take two measurements, one of weight and one of fat
mass, in order to diagnose obesity. Some measurements of weight and body fat that do not require using technical equipment can
easily be calculated and help provide an individual with information on weight, fat mass, and distribution, and their relative risk of
some chronic diseases.

Figure : Body Composition. Image by Allison Calabrese / CC BY

4.0

Body Mass Index: How to Measure It and Its Limitations

Body mass index (BMI) is calculated using height and weight measurements and is more predictive of body fatness than weight
alone. BMI measurements are used to indicate whether an individual may be underweight (with a BMI less than 18.5), overweight
(with a BMI over 25), or obese (with a BMI over 30). High BMI measurements can be warning signs of health hazards ahead, such
as cardiovascular disease, Type 2 diabetes, and other chronic diseases. BMI-associated health risks vary by race. Asians face
greater health risks for the same BMI than Caucasians, and Caucasians face greater health risks for the same BMI than African
Americans.

Calculating BMI
To calculate your BMI, multiply your weight in pounds by 703 (conversion factor for converting to metric units) and then divide
the product by your height in inches, squared.

3.13.1 [Link]
or

More Ways to Calculate

The National Heart, Lung, and Blood Institute and the CDC have automatic BMI calculators on their websites:
[Link]/bmi/
[Link]
To see how your BMI indicates the weight category you are in, see Table .
Table : BMI Categories
Categories BMI

Underweight < 18.5

Healthy or Normal weight 18.5–24.9

Overweight 25–29.9

Obese > 30.0

Source: National Heart, Lung, and Blood Institute. Accessed November 4, 2012. [Link]

BMI Limitations
A BMI is a fairly simple measurement and does not take into account fat mass or fat distribution in the body, both of which are
additional predictors of disease risk. Body fat weighs less than muscle mass. Therefore, BMI can sometimes underestimate the
amount of body fat in overweight or obese people and overestimate it in more muscular people. For instance, a muscular athlete
will have more muscle mass (which is heavier than fat mass) than a sedentary individual of the same height. Based on their BMIs
the muscular athlete would be less “ideal” and may be categorized as more overweight or obese than the sedentary individual;
however this is an infrequent problem with BMI calculation. Additionally, an older person with osteoporosis (decreased bone mass)
will have a lower BMI than an older person of the same height without osteoporosis, even though the person with osteoporosis may
have more fat mass. BMI is a useful inexpensive tool to categorize people and is highly correlative with disease risk, but other
measurements are needed to diagnose obesity and more accurately assess disease risk.

Body Fat and Its Distribution

Next we’ll discuss how to measure body fat, and why distribution of body fat is also important to consider when determining
health.

Measuring Body Fat Content

Water, organs, bone tissue, fat, and muscle tissue make up a person’s weight. Having more fat mass may be indicative of disease
risk, but fat mass also varies with sex, age, and physical activity level. Females have more fat mass, which is needed for
reproduction and, in part, is a consequence of different levels of hormones. The optimal fat content of a female is between 20 and
30 percent of her total weight and for a male is between 12 and 20 percent. Fat mass can be measured in a variety of ways. The
simplest and lowest-cost way is the skin-fold test. A health professional uses a caliper to measure the thickness of skin on the back,
arm, and other parts of the body and compares it to standards to assess body fatness. It is a noninvasive and fairly accurate method
of measuring fat mass, but similar to BMI, is compared to standards of mostly young to middle-aged adults.

3.13.2 [Link]
 Figure : Measuring Skinfold Thickness Using Calipers. Image by
Shutterstock. All Rights Reserved.
Other methods of measuring fat mass are more expensive and more technically challenging. They include:
Underwater weighing. This technique requires a chamber full of water big enough for the whole body to fit in. First, a person is
weighed outside the chamber and then weighed again while immersed in water. Bone and muscle weigh more than water, but
fat does not—therefore a person with a higher muscle and bone mass will weigh more when in water than a person with less
bone and muscle mass.
Bioelectric Impedance Analysis (BIA). This device is based on the fact that fat slows down the passage of electricity through
the body. When a small amount of electricity is passed through the body, the rate at which it travels is used to determine body
composition. These devices are also sold for home use and commonly called body composition scales.

Figure : BIA Hand Device. Image by United

States Marine Corps / Public Domain
Dual-energy X-ray absorptiometry (DEXA). This can be used to measure bone density. It also can determine fat content via the
same method, which directs two low-dose X-ray beams through the body and determines the amount of the energy absorbed
from the beams. The amount of energy absorbed is dependent on the body’s content of bone, lean tissue mass, and fat mass.
Using standard mathematical formulas, fat content can be accurately estimated.

3.13.3 [Link]
 Figure : Dual-Energy X-ray Absorptiometry
(DEXA). “A Dual-energy X-ray absorptiometry (DEXA) scan” by Nick Smith / CC BY-SA 3.0

Measuring Fat Distribution

Total body-fat mass is one predictor of health; another is how the fat is distributed in the body. You may have heard that fat on the
hips is better than fat in the belly—this is true. Fat can be found in different areas in the body and it does not all act the same,
meaning it differs physiologically based on location. Fat deposited in the abdominal cavity is called visceral fat and it is a better
predictor of disease risk than total fat mass. Visceral fat releases hormones and inflammatory factors that contribute to disease risk.
The only tool required for measuring visceral fat is a measuring tape. The measurement (of waist circumference) is taken just
above the belly button. Men with a waist circumference greater than 40 inches and women with a waist circumference greater than
35 inches are predicted to face greater health risks.

Figure : Fat Distribution. Image by Allison Calabrese / CC BY 4.0

The waist-to-hip ratio is often considered a better measurement than waist circumference alone in predicting disease risk. To
calculate your waist-to-hip ratio, use a measuring tape to measure your waist circumference and then measure your hip
circumference at its widest part. Next, divide the waist circumference by the hip circumference to arrive at the waist-to-hip ratio
(Figure ). Observational studies have demonstrated that people with “apple-shaped” bodies, (who carry more weight around
the waist) have greater risks for chronic disease than those with “pear-shaped” bodies, (who carry more weight around the hips). A
study published in the November 2005 issue of Lancet with more than twenty-seven thousand participants from fifty-two countries
concluded that the waist-to-hip ratio is highly correlated with heart attack risk worldwide and is a better predictor of heart attacks

3.13.4 [Link]
than BMI.[1]. Abdominal obesity is defined by the World Health Organization (WHO) as having a waist-to-hip ratio above 0.90 for
males and above 0.85 for females.
1. Yusuf S, Hawken S, et al. (2005). Obesity and the Risk of Myocardial Infarction in 27,000 Participants from 52 Countries: A
Case-Control Study. Lancet, 366(9497), 1640–9. [Link]

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3.13.5 [Link]
 CHAPTER OVERVIEW

4: Carbohydrates
Learning Objectives
By the end of this chapter, you will be able to:
Describe the different types of simple and complex carbohydrates
Describe the process of carbohydrate digestion and absorption
Describe the functions of carbohydrates in the body
Describe the body’s carbohydrate needs and how personal choices can lead to health benefits or consequences

4.1: Introduction to Carbohydrates

4.2: Digestion and Absorption of Carbohydrates
4.3: The Functions of Carbohydrates in the Body
4.4: Health Consequences and Benefits of High-Carbohydrate Diets
4.5: Looking Closely at Diabetes
4.6: Carbohydrates and Personal Diet Choices
4.7: The Food Industry- Functional Attributes of Carbohydrates and the Use of Sugar Substitutes

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1
4.1: Introduction to Carbohydrates
E ʻai i ka mea i loaʻa
What you have, eat

Figure : Two Breadfruit by Michael Coghlan / CC BY-SA 2.0

Throughout history, carbohydrates have and continue to be a major source of people’s diets worldwide. In ancient Hawai‘i the
Hawaiians obtained the majority of their calories from carbohydrate rich plants like the ‘uala (sweet potato), ulu (breadfruit) and
kalo (taro). For example, mashed kalo or poi was a staple to meals for Hawaiians. Research suggests that almost 78 percent of the
diet was made up of these fiber rich carbohydrate foods.[1]
Carbohydrates are the perfect nutrient to meet your body’s nutritional needs. They nourish your brain and nervous system, provide
energy to all of your cells when within proper caloric limits, and help keep your body fit and lean. Specifically, digestible
carbohydrates provide bulk in foods, vitamins, and minerals, while indigestible carbohydrates provide a good amount of fiber with
a host of other health benefits.
Plants synthesize the fast-releasing carbohydrate, glucose, from carbon dioxide in the air and water, and by harnessing the sun’s
energy. Recall that plants convert the energy in sunlight to chemical energy in the molecule, glucose. Plants use glucose to make
other larger, more slow-releasing carbohydrates. When we eat plants we harvest the energy of glucose to support life’s processes.

Figure : Carbohydrate Classification Scheme.

Carbohydrates are broken down into the subgroups simple and complex carbohydrates. These subgroups are further categorized
into mono-, di-, and polysaccharides.

4.1.1 [Link]
Carbohydrates are a group of organic compounds containing a ratio of one carbon atom to two hydrogen atoms to one oxygen
atom. Basically, they are hydrated carbons. The word “carbo” means carbon and “hydrate” means water. Glucose, the most
abundant carbohydrate in the human body, has six carbon atoms, twelve hydrogen atoms, and six oxygen atoms. The chemical
formula for glucose is written as . Synonymous with the term carbohydrate is the Greek word “saccharide,” which means
sugar. The simplest unit of a carbohydrate is a monosaccharide. Carbohydrates are broadly classified into two subgroups, simple
(“fast-releasing”) and complex (“slow-releasing”). Simple carbohydrates are further grouped into the monosaccharides and
disaccharides. Complex carbohydrates are long chains of monosaccharides.

Simple/Fast-Releasing Carbohydrates
Simple carbohydrates are also known more simply as “sugars” and are grouped as either monosaccharides or disaccharides.
Monosaccharides include glucose, fructose, and galactose, and the disaccharides include lactose, maltose, and sucrose.
Simple carbohydrates stimulate the sweetness taste sensation, which is the most sensitive of all taste sensations. Even extremely
low concentrations of sugars in foods will stimulate the sweetness taste sensation. Sweetness varies between the different
carbohydrate types—some are much sweeter than others. Fructose is the top naturally-occurring sugar in sweetness value.

Monosaccharides
For all organisms from bacteria to plants to animals, glucose is the preferred fuel source. The brain is completely dependent on
glucose as its energy source (except during extreme starvation conditions). The monosaccharide galactose differs from glucose only
in that a hydroxyl (−OH) group faces in a different direction on the number four carbon (Figure ). This small structural
alteration causes galactose to be less stable than glucose. As a result, the liver rapidly converts it to glucose. Most absorbed
galactose is utilized for energy production in cells after its conversion to glucose. (Galactose is one of two simple sugars that are
bound together to make up the sugar found in milk. It is later freed during the digestion process.)
Fructose also has the same chemical formula as glucose but differs in its chemical structure. The fructose ring contains 4 carbons
while the glucose ring contains 5 carbons. Fructose, in contrast to glucose, is not an energy source for other cells in the body.
Mostly found in fruits, honey, and sugarcane, fructose is one of the most common monosaccharides in nature. It is also found in
soft drinks, cereals, and other products sweetened with high fructose corn syrup.

Figure : Structures of the Three Most

Common Monosaccharides: Glucose, Galactose, and Fructose. Circles indicate the structural differences between the three.
Pentoses are less common monosaccharides which have only five carbons and not six. The pentoses are abundant in the nucleic
acids RNA and DNA, and also as components of fiber.
Lastly, there are the sugar alcohols, which are industrially synthesized derivatives of monosaccharides. Some examples of sugar
alcohols are sorbitol, xylitol, and glycerol. (Xylitol is similar in sweetness as table sugar). Sugar alcohols are often used in place of
table sugar to sweeten foods as they are incompletely digested and absorbed, and therefore less caloric. The bacteria in your mouth
opposes them, hence sugar alcohols do not cause tooth decay. Interestingly, the sensation of “coolness” that occurs when chewing
gum that contains sugar alcohols comes from them dissolving in the mouth, a chemical reaction that requires heat from the inside
of the mouth.

Disaccharides
Disaccharides are composed of pairs of two monosaccharides linked together. Disaccharides include sucrose, lactose, and maltose.
All of the disaccharides contain at least one glucose molecule.

4.1.2 [Link]
Sucrose, which contains both glucose and fructose molecules, is otherwise known as table sugar. Sucrose is also found in many
fruits and vegetables, and at high concentrations in sugar beets and sugarcane, which are used to make table sugar. Lactose, which
is commonly known as milk sugar, is composed of one glucose unit and one galactose unit. Lactose is prevalent in dairy products
such as milk, yogurt, and cheese. Maltose consists of two glucose molecules bonded together. It is a common breakdown product
of plant starches and is rarely found in foods as a disaccharide.

Figure : The Most Common

Disaccharides. Image by Allison Calabrese / CC BY 4.0

Complex/Slow-Releasing Carbohydrates
Complex carbohydrates are polysaccharides, long chains of monosaccharides that may be branched or not branched. There are two
main groups of polysaccharides: starches and fibers.

Starches
Starch molecules are found in abundance in grains, legumes, and root vegetables, such as potatoes. Amylose, a plant starch, is a
linear chain containing hundreds of glucose units. Amylopectin, another plant starch, is a branched chain containing thousands of
glucose units. These large starch molecules form crystals and are the energy-storing molecules of plants. These two starch
molecules (amylose and amylopectin) are contained together in foods, but the smaller one, amylose, is less abundant. Eating raw
foods containing starches provides very little energy as the digestive system has a hard time breaking them down. Cooking breaks
down the crystal structure of starches, making them much easier to break down in the human body. The starches that remain intact
throughout digestion are called resistant starches. Bacteria in the gut can break some of these down and may benefit gastrointestinal
health. Isolated and modified starches are used widely in the food industry and during cooking as food thickeners.

4.1.3 [Link]
 Figure : Structures of the Plant Starches and
Glycogen
Humans and animals store glucose energy from starches in the form of the very large molecule, glycogen. It has many branches
that allow it to break down quickly when energy is needed by cells in the body. It is predominantly found in liver and muscle tissue
in animals.

Dietary Fibers
Dietary fibers are polysaccharides that are highly branched and cross-linked. Some dietary fibers are pectin, gums, cellulose,
hemicellulose, and lignin. Lignin, however, is not composed of carbohydrate units. Humans do not produce the enzymes that can
break down dietary fiber; however, bacteria in the large intestine (colon) do. Dietary fibers are very beneficial to our health. The
Dietary Guidelines Advisory Committee states that there is enough scientific evidence to support that diets high in fiber reduce the
risk for obesity and diabetes, which are primary risk factors for cardiovascular disease.[2]
Dietary fiber is categorized as either water-soluble or insoluble. Some examples of soluble fibers are inulin, pectin, and guar gum
and they are found in peas, beans, oats, barley, and rye. Cellulose and lignin are insoluble fibers and a few dietary sources of them
are whole-grain foods, flax, cauliflower, and avocados. Cellulose is the most abundant fiber in plants, making up the cell walls and
providing structure. Soluble fibers are more easily accessible to bacterial enzymes in the large intestine so they can be broken down
to a greater extent than insoluble fibers, but even some breakdown of cellulose and other insoluble fibers occurs.
The last class of fiber is functional fiber. Functional fibers have been added to foods and have been shown to provide health
benefits to humans. Functional fibers may be extracted from plants and purified or synthetically made. An example of a functional
fiber is psyllium-seed husk. Scientific studies show that consuming psyllium-seed husk reduces blood-cholesterol levels and this
health claim has been approved by the FDA. Total dietary fiber intake is the sum of dietary fiber and functional fiber consumed.

Figure : Image by Allison Calabrese / CC BY 4.0

4.1.4 [Link]
Learning Activities
1. Fujita R, Braun KL, Hughes CK. (2004). The traditional Hawaiian diet: a review of the literature. Pacific Health Dialogue,
11(2). [Link] Accessed October 19,
2017. ↵
2. US Department of Agriculture. Part D. Section 5: Carbohydrates. In Report of the DGAC on the Dietary Guidelines for
Americans, 2010. [Link]/Publications/DietaryGuidelines/2010/DGAC/Report/[Link]. Accessed
September 30, 2011. ↵

This page titled 4.1: Introduction to Carbohydrates is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by
Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
4.1: Introduction to Carbohydrates by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0.
Original source: [Link]

4.1.5 [Link]
4.2: Digestion and Absorption of Carbohydrates
From the Mouth to the Stomach
The mechanical and chemical digestion of carbohydrates begins in the mouth. Chewing, also known as mastication, crumbles the
carbohydrate foods into smaller and smaller pieces. The salivary glands in the oral cavity secrete saliva that coats the food particles.
Saliva contains the enzyme, salivary amylase. This enzyme breaks the bonds between the monomeric sugar units of disaccharides,
oligosaccharides, and starches. The salivary amylase breaks down amylose and amylopectin into smaller chains of glucose, called
dextrins and maltose. The increased concentration of maltose in the mouth that results from the mechanical and chemical
breakdown of starches in whole grains is what enhances their sweetness. Only about five percent of starches are broken down in the
mouth. (This is a good thing as more glucose in the mouth would lead to more tooth decay.) When carbohydrates reach the stomach
no further chemical breakdown occurs because the amylase enzyme does not function in the acidic conditions of the stomach. But
mechanical breakdown is ongoing—the strong peristaltic contractions of the stomach mix the carbohydrates into the more uniform
mixture of chyme.

Figure : Salivary Glands in the Mouth.

Salivary glands secrete salivary amylase, which begins the chemical breakdown of carbohydrates by breaking the bonds between
monomeric sugar units.

From the Stomach to the Small Intestine

The chyme is gradually expelled into the upper part of the small intestine. Upon entry of the chyme into the small intestine, the
pancreas releases pancreatic juice through a duct. This pancreatic juice contains the enzyme, pancreatic amylase, which starts again
the breakdown of dextrins into shorter and shorter carbohydrate chains. Additionally, enzymes are secreted by the intestinal cells
that line the villi. These enzymes, known collectively as disaccharidase, are sucrase, maltase, and lactase. Sucrase breaks sucrose
into glucose and fructose molecules. Maltase breaks the bond between the two glucose units of maltose, and lactase breaks the
bond between galactose and glucose. Once carbohydrates are chemically broken down into single sugar units they are then
transported into the inside of intestinal cells.

4.2.1 [Link]
When people do not have enough of the enzyme lactase, lactose is not sufficiently broken down resulting in a condition called
lactose intolerance. The undigested lactose moves to the large intestine where bacteria are able to digest it. The bacterial digestion
of lactose produces gases leading to symptoms of diarrhea, bloating, and abdominal cramps. Lactose intolerance usually occurs in
adults and is associated with race. The National Digestive Diseases Information Clearing House states that African Americans,
Hispanic Americans, American Indians, and Asian Americans have much higher incidences of lactose intolerance while those of
northern European descent have the least.[1] Most people with lactose intolerance can tolerate some amount of dairy products in
their diet. The severity of the symptoms depends on how much lactose is consumed and the degree of lactase deficiency.

Absorption: Going to the Blood Stream

The cells in the small intestine have membranes that contain many transport proteins in order to get the monosaccharides and other
nutrients into the blood where they can be distributed to the rest of the body. The first organ to receive glucose, fructose, and
galactose is the liver. The liver takes them up and converts galactose to glucose, breaks fructose into even smaller carbon-
containing units, and either stores glucose as glycogen or exports it back to the blood. How much glucose the liver exports to the
blood is under hormonal control and you will soon discover that even the glucose itself regulates its concentrations in the blood.

Figure : Carbohydrate
Digestion. Carbohydrate digestion begins in the mouth and is most extensive in the small intestine. The resultant monosaccharides
are absorbed into the bloodstream and transported to the liver.

Maintaining Blood Glucose Levels: The Pancreas and Liver

Glucose levels in the blood are tightly controlled, as having either too much or too little glucose in the blood can have health
consequences. Glucose regulates its levels in the blood via a process called negative feedback. An everyday example of negative
feedback is in your oven because it contains a thermostat. When you set the temperature to cook a delicious homemade noodle
casserole at 375°F the thermostat senses the temperature and sends an electrical signal to turn the elements on and heat up the oven.
When the temperature reaches 375°F the thermostat senses the temperature and sends a signal to turn the element off. Similarly,
your body senses blood glucose levels and maintains the glucose “temperature” in the target range. The glucose thermostat is
located within the cells of the pancreas. After eating a meal containing carbohydrates glucose levels rise in the blood.
Insulin-secreting cells in the pancreas sense the increase in blood glucose and release the hormone, insulin, into the blood. Insulin
sends a signal to the body’s cells to remove glucose from the blood by transporting it into different organ cells around the body and

4.2.2 [Link]
using it to make energy. In the case of muscle tissue and the liver, insulin sends the biological message to store glucose away as
glycogen. The presence of insulin in the blood signifies to the body that glucose is available for fuel. As glucose is transported into
the cells around the body, the blood glucose levels decrease. Insulin has an opposing hormone called glucagon. Glucagon-secreting
cells in the pancreas sense the drop in glucose and, in response, release glucagon into the blood. Glucagon communicates to the
cells in the body to stop using all the glucose. More specifically, it signals the liver to break down glycogen and release the stored
glucose into the blood, so that glucose levels stay within the target range and all cells get the needed fuel to function properly.

Figure : The Regulation of Glucose.

Image by Allison Calabrese / CC BY 4.0

Leftover Carbohydrates: The Large Intestine

Almost all of the carbohydrates, except for dietary fiber and resistant starches, are efficiently digested and absorbed into the body.
Some of the remaining indigestible carbohydrates are broken down by enzymes released by bacteria in the large intestine. The
products of bacterial digestion of these slow-releasing carbohydrates are short-chain fatty acids and some gases. The short-chain
fatty acids are either used by the bacteria to make energy and grow, are eliminated in the feces, or are absorbed into cells of the
colon, with a small amount being transported to the liver. Colonic cells use the short-chain fatty acids to support some of their
functions. The liver can also metabolize the short-chain fatty acids into cellular energy. The yield of energy from dietary fiber is
about 2 kilocalories per gram for humans, but is highly dependent upon the fiber type, with soluble fibers and resistant starches
yielding more energy than insoluble fibers. Since dietary fiber is digested much less in the gastrointestinal tract than other
carbohydrate types (simple sugars, many starches) the rise in blood glucose after eating them is less, and slower. These
physiological attributes of high-fiber foods (i.e. whole grains) are linked to a decrease in weight gain and reduced risk of chronic
diseases, such as Type 2 diabetes and cardiovascular disease.

4.2.3 [Link]
 Figure : Overview of
Carbohydrate Digestion. Image by Allison Calabrese / CC BY 4.0

A Carbohydrate Feast
You are at a your grandma’s house for family dinner and you just consumed kalua pig, white rice, sweet potatoes, mac salad,
chicken long rice and a hot sweet bread roll dripping with butter. Less than an hour later you top it off with a slice of haupia pie and
then lie down on the couch to watch TV. The “hormone of plenty,” insulin, answers the nutrient call. Insulin sends out the
physiological message that glucose is abundant in the blood, so that cells can absorb it and either use it or store it. The result of this
hormone message is maximization of glycogen stores and all the excess glucose, protein, and lipids are stored as fat.

Figure : Image by Allison Calabrese /

CC BY 4.0
A typical American Thanksgiving meal contains many foods that are dense in carbohydrates, with the majority of those being
simple sugars and starches. These types of carbohydrate foods are rapidly digested and absorbed. Blood glucose levels rise quickly
causing a spike in insulin levels. Contrastingly, foods containing high amounts of fiber are like time-release capsules of sugar. A
measurement of the effects of a carbohydrate-containing food on blood-glucose levels is called the glycemic response.

Glycemic Index
The glycemic responses of various foods have been measured and then ranked in comparison to a reference food, usually a slice of
white bread or just straight glucose, to create a numeric value called the glycemic index (GI). Foods that have a low GI do not raise
blood-glucose levels neither as much nor as fast as foods that have a higher GI. A diet of low-GI foods has been shown in
epidemiological and clinical trial studies to increase weight loss and reduce the risk of obesity, Type 2 diabetes, and cardiovascular
disease.[2]

4.2.4 [Link]
Table : The Glycemic Index: Foods In Comparison To Glucose

4.2.5 [Link]
 Foods GI Value

Low GI Foods (< 55)

Apple, raw 36

Orange, raw 43

Banana, raw 51

Mango, raw 51

Carrots, boiled 39

Taro, boiled 53

Corn tortilla 46

Spaghetti (whole wheat) 37

Baked beans 48

Soy milk 34

Skim milk 37

Whole milk 39

Yogurt, fruit 41

Yogurt, plain 14

Icecream 51

Medium GI Foods (56–69)

Pineapple, raw 59

Cantaloupe 65

Mashed potatoes 70

Whole-wheat bread 69

Brown rice 55

Cheese pizza 60

Sweet potato, boiled 63

Macaroni and cheese 64

Popcorn 65

High GI Foods (70 and higher)

Banana (over-ripe) 82

Corn chips 72

Pretzels 83

White bread 70

White rice 72

Bagel 72

4.2.6 [Link]
 Foods GI Value

Rice milk 86

Cheerios 74

Raisin Bran 73

Fruit roll-up 99

Gatorade 78

For the Glycemic Index on different foods, visit [Link]

The type of carbohydrate within a food affects the GI along with its fat and fiber content. Increased fat and fiber in foods increases
the time required for digestion and delays the rate of gastric emptying into the small intestine which, ultimately reduces the GI.
Processing and cooking also affects a food’s GI by increasing their digestibility. Advancements in the technologies of food
processing and the high consumer demand for convenient, precooked foods in the United States has created foods that are digested
and absorbed more rapidly, independent of the fiber content. Modern breakfast cereals, breads, pastas, and many prepared foods
have a high GI. In contrast, most raw foods have a lower GI. (However, the more ripened a fruit or vegetable is, the higher its GI.)
The GI can be used as a guide for choosing healthier carbohydrate choices but has some limitations. The first is GI does not take
into account the amount of carbohydrates in a portion of food, only the type of carbohydrate. Another is that combining low- and
high-GI foods changes the GI for the meal. Also, some nutrient-dense foods have higher GIs than less nutritious food. (For
instance, oatmeal has a higher GI than chocolate because the fat content of chocolate is higher.) Lastly, meats and fats do not have a
GI since they do not contain carbohydrates.

More Resources
Visit this online database to discover the glycemic indices of foods. Foods are listed by category and also by low, medium, or high
glycemic index.
[Link]

Learning Activities
1. Lactose Intolerance. National Digestive Diseases Information Clearing House.
[Link]/ddiseases/pubs/lactoseintolerance/. Updated April 23, 2012. Accessed September 22, 2017. ↵
2. Brand-Miller J, et al. (2009). Dietary Glycemic Index: Health Implications. Journal of the American College of Nutrition, 28(4),
446S–[Link]://[Link]/pubmed/20234031. Accessed September 27, 2017. ↵

This page titled 4.2: Digestion and Absorption of Carbohydrates is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or
curated by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
4.2: Digestion and Absorption of Carbohydrates by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC
BY-NC-SA 4.0. Original source: [Link]

4.2.7 [Link]
4.3: The Functions of Carbohydrates in the Body
There are five primary functions of carbohydrates in the human body. They are energy production, energy storage, building
macromolecules, sparing protein, and assisting in lipid metabolism.

Energy Production
The primary role of carbohydrates is to supply energy to all cells in the body. Many cells prefer glucose as a source of energy
versus other compounds like fatty acids. Some cells, such as red blood cells, are only able to produce cellular energy from glucose.
The brain is also highly sensitive to low blood-glucose levels because it uses only glucose to produce energy and function (unless
under extreme starvation conditions). About 70 percent of the glucose entering the body from digestion is redistributed (by the
liver) back into the blood for use by other tissues. Cells that require energy remove the glucose from the blood with a transport
protein in their membranes. The energy from glucose comes from the chemical bonds between the carbon atoms. Sunlight energy
was required to produce these high-energy bonds in the process of photosynthesis. Cells in our bodies break these bonds and
capture the energy to perform cellular respiration. Cellular respiration is basically a controlled burning of glucose versus an
uncontrolled burning. A cell uses many chemical reactions in multiple enzymatic steps to slow the release of energy (no explosion)
and more efficiently capture the energy held within the chemical bonds in glucose.
The first stage in the breakdown of glucose is called glycolysis. Glycolysis, or the splitting of glucose, occurs in an intricate series
of ten enzymatic-reaction steps. The second stage of glucose breakdown occurs in the energy factory organelles, called
mitochondria. One carbon atom and two oxygen atoms are removed, yielding more energy. The energy from these carbon bonds is
carried to another area of the mitochondria, making the cellular energy available in a form cells can use.

Figure : Cellular Respiration. Image by Allison Calabrese /

CC BY 4.0
Cellular respiration is the process by which energy is captured from glucose.

Energy Storage
If the body already has enough energy to support its functions, the excess glucose is stored as glycogen (the majority of which is
stored in the muscles and liver). A molecule of glycogen may contain in excess of fifty thousand single glucose units and is highly
branched, allowing for the rapid dissemination of glucose when it is needed to make cellular energy.
The amount of glycogen in the body at any one time is equivalent to about 4,000 kilocalories—3,000 in muscle tissue and 1,000 in
the liver. Prolonged muscle use (such as exercise for longer than a few hours) can deplete the glycogen energy reserve. Remember
that this is referred to as “hitting the wall” or “bonking” and is characterized by fatigue and a decrease in exercise performance. The
weakening of muscles sets in because it takes longer to transform the chemical energy in fatty acids and proteins to usable energy
than glucose. After prolonged exercise, glycogen is gone and muscles must rely more on lipids and proteins as an energy source.
Athletes can increase their glycogen reserve modestly by reducing training intensity and increasing their carbohydrate intake to
between 60 and 70 percent of total calories three to five days prior to an event. People who are not hardcore training and choose to

4.3.1 [Link]
run a 5-kilometer race for fun do not need to consume a big plate of pasta prior to a race since without long-term intense training
the adaptation of increased muscle glycogen will not happen.
The liver, like muscle, can store glucose energy as a glycogen, but in contrast to muscle tissue it will sacrifice its stored glucose
energy to other tissues in the body when blood glucose is low. Approximately one-quarter of total body glycogen content is in the
liver (which is equivalent to about a four-hour supply of glucose) but this is highly dependent on activity level. The liver uses this
glycogen reserve as a way to keep blood-glucose levels within a narrow range between meal times. When the liver’s glycogen
supply is exhausted, glucose is made from amino acids obtained from the destruction of proteins in order to maintain metabolic
homeostasis.

Building Macromolecules
Although most absorbed glucose is used to make energy, some glucose is converted to ribose and deoxyribose, which are essential
building blocks of important macromolecules, such as RNA, DNA, and ATP. Glucose is additionally utilized to make the molecule
NADPH, which is important for protection against oxidative stress and is used in many other chemical reactions in the body. If all
of the energy, glycogen-storing capacity, and building needs of the body are met, excess glucose can be used to make fat. This is
why a diet too high in carbohydrates and calories can add on the fat pounds—a topic that will be discussed shortly.

Figure : Chemical Structure of Deoxyribose. The sugar molecule deoxyribose is used to build the

backbone of DNA. Image by rozeta / CC BY-SA 3.0 Figure :

Double-stranded DNA. Image by Forluvoft / Public Domain

Sparing Protein
In a situation where there is not enough glucose to meet the body’s needs, glucose is synthesized from amino acids. Because there
is no storage molecule of amino acids, this process requires the destruction of proteins, primarily from muscle tissue. The presence
of adequate glucose basically spares the breakdown of proteins from being used to make glucose needed by the body.

Lipid Metabolism
As blood-glucose levels rise, the use of lipids as an energy source is inhibited. Thus, glucose additionally has a “fat-sparing” effect.
This is because an increase in blood glucose stimulates release of the hormone insulin, which tells cells to use glucose (instead of

4.3.2 [Link]
lipids) to make energy. Adequate glucose levels in the blood also prevent the development of ketosis. Ketosis is a metabolic
condition resulting from an elevation of ketone bodies in the blood. Ketone bodies are an alternative energy source that cells can
use when glucose supply is insufficient, such as during fasting. Ketone bodies are acidic and high elevations in the blood can cause
it to become too acidic. This is rare in healthy adults, but can occur in alcoholics, people who are malnourished, and in individuals
who have Type 1 diabetes. The minimum amount of carbohydrate in the diet required to inhibit ketosis in adults is 50 grams per
day.
Carbohydrates are critical to support life’s most basic function—the production of energy. Without energy none of the other life
processes are performed. Although our bodies can synthesize glucose it comes at the cost of protein destruction. As with all
nutrients though, carbohydrates are to be consumed in moderation as having too much or too little in the diet may lead to health
problems.

Learning Activities

This page titled 4.3: The Functions of Carbohydrates in the Body is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or
curated by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
4.3: The Functions of Carbohydrates in the Body by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC
BY-NC-SA 4.0. Original source: [Link]

4.3.3 [Link]
4.4: Health Consequences and Benefits of High-Carbohydrate Diets
Can America blame its obesity epidemic on the higher consumption of added sugars and refined grains? This is a hotly debated
topic by both the scientific community and the general public. In this section, we will give a brief overview of the scientific
evidence.

Added Sugars
The Food and Nutrition Board of the Institute of Medicine (IOM) defines added sugars as “sugars and syrups that are added to
foods during processing or preparation.” The IOM goes on to state, “Major sources of added sugars include soft drinks, sports
drinks, cakes, cookies, pies, fruitades, fruit punch, dairy desserts, and candy.” Processed foods, even microwaveable dinners, also
contain added sugars. Added sugars do not include sugars that occur naturally in whole foods (such as an apple), but do include
natural sugars such as brown sugar, corn syrup, dextrose, fructose, fruit juice concentrates, maple syrup, sucrose, and raw sugar that
are then added to create other foods (such as cookies). Results from a survey of forty-two thousand Americans reports that in 2008
the average intake of added sugars is 15 percent of total calories, a drop from 18 percent of total calories in 2000.[1]

Figure : Sugar Consumption

(In Teaspoons) From Various Sources. Image by Forluvoft / Public Domain
This is still above the recommended intake of less than 10 percent of total calories. The US Department of Agriculture (USDA)
reports that sugar consumption in the American diet in 2008 was, on average, 28 teaspoons per day (Figure 4.13).

Obesity, Diabetes, and Heart Disease and Their Hypothesized Link to Excessive Sugar and Refined
Carbohydrate Consumption
To understand the magnitude of the health problem in the United States consider this—in the United States approximately 130
million adults are overweight, and 30 percent of them are considered obese. The obesity epidemic has reached young adults and
children and will markedly affect the prevalence of serious health consequences in adulthood. Health consequences linked to being
overweight or obese include Type 2 diabetes, cardiovascular disease, arthritis, depression, and some cancers. An infatuation with
sugary foods and refined grains likely contributes to the epidemic proportion of people who are overweight or obese in this country,
but so do the consumption of high-calorie foods that contain too much saturated fat and the sedentary lifestyle of most Americans.
There is much disagreement over whether high-carbohydrate diets increase weight-gain and disease risk, especially when calories
are not significantly higher between compared diets. Many scientific studies demonstrate positive correlations between diets high
in added sugars with weight gain and disease risk, but some others do not show a significant relationship. In regard to refined
grains, there are no studies that show consumption of refined grains increases weight gain or disease risk. What is clear, however, is

4.4.1 [Link]
that getting more of your carbohydrates from dietary sources containing whole grains instead of refined grains stimulates weight
loss and reduces disease risk.
A major source of added sugars in the American diet is soft drinks. There is consistent scientific evidence that consuming sugary
soft drinks increases weight gain and disease risk. An analysis of over thirty studies in the American Journal of Clinical Nutrition
concluded that there is much evidence to indicate higher consumption of sugar-sweetened beverages is linked with weight gain and
obesity.[2] A study at the Harvard School of Public Health linked the consumption of sugary soft drinks to an increased risk for
heart disease.[3]
While the sugar and refined grains and weight debate rages on, the results of all of these studies has led some public health
organizations like the American Heart Association (AHA) to recommend even a lower intake of sugar per day (fewer than 9
teaspoons per day for men and fewer than 6 teaspoons for women) than what used to be deemed acceptable. After its 2010
scientific conference on added sugars, the AHA made the following related dietary recommendations[4]:
First, know the number of total calories you should eat each day.
Consume an overall healthy diet and get the most nutrients for the calories, using foods high in added sugars as discretionary
calories (those left over after getting all recommended nutrients subtracted from the calories used).
Lower sugar intake, especially when the sugars in foods are not tied to positive nutrients such as in sugary drinks, candies,
cakes, and cookies.
Focus on calories in certain food categories such as beverages and confections, and encourage consumption of positive nutrients
and foods such as cereals and low-fat or fat-free dairy products.

The Most Notorious Sugar

Before high-fructose corn syrup (HFCS) was marketed as the best food and beverage sweetener, sucrose (table sugar) was the
number-one sweetener in America. (Recall that sucrose, or table sugar, is a disaccharide consisting of one glucose unit and one
fructose unit.) HFCS also contains the simple sugars fructose and glucose, but with fructose at a slightly higher concentration. In
the production of HFCS, corn starch is broken down to glucose, and some of the glucose is then converted to fructose. Fructose is
sweeter than glucose; hence many food manufacturers choose to sweeten foods with HFCS. HFCS is used as a sweetener for
carbonated beverages, condiments, cereals, and a great variety of other processed foods.
Some scientists, public health personnel, and healthcare providers believe that fructose is the cause of the obesity epidemic and its
associated health consequences. The majority of their evidence stems from the observation that since the early 1970s the number of
overweight or obese Americans has dramatically increased and so has the consumption of foods containing HFCS. However, as
discussed, so has the consumption of added sugars in general. Animal studies that fuel the fructose opponents show fructose is not
used to produce energy in the body; instead it is mostly converted to fat in the liver—potentially contributing to insulin resistance
and the development of Type 2 diabetes. Additionally, fructose does not stimulate the release of certain appetite-suppressing
hormones, like insulin, as glucose does. Thus, a diet high in fructose could potentially stimulate fat deposition and weight gain.
In human studies, excessive fructose intake has sometimes been associated with weight gain, but results are inconsistent. Moderate
fructose intake is not associated with weight gain at all. Moreover, other studies show that some fructose in the diet actually
improves glucose metabolism especially in people with Type 2 diabetes.[5]
In fact, people with diabetes were once advised to use fructose as an alternative sweetener to table sugar. Overall, there is no good
evidence that moderate fructose consumption contributes to weight gain and chronic disease. At this time conclusive evidence is
not available on whether fructose is any worse than any other added sugar in increasing the risk for obesity, Type 2 diabetes, and
cardiovascular disease.

Do Low-Carbohydrate Diets Affect Health?

Since the early 1990s, marketers of low-carbohydrate diets have bombarded us with the idea that eating fewer carbohydrates
promotes weight loss and that these diets are superior to others in their effects on weight loss and overall health. The most famous
of these low-carbohydrate diets is the Atkins diet. Others include the “South Beach” diet, the “Zone” diet, and the “Earth” diet.
Despite the claims these diets make, there is little scientific evidence to support that low-carbohydrate diets are significantly better
than other diets in promoting long-term weight loss. A study in The Nutritional Journal concluded that all diets, (independent of

4.4.2 [Link]
carbohydrate, fat, and protein content) that incorporated an exercise regimen significantly decreased weight and waist
circumference in obese women.[6]
Some studies do provide evidence that in comparison to other diets, low-carbohydrate diets improve insulin levels and other risk
factors for Type 2 diabetes and cardiovascular disease. The overall scientific consensus is that consuming fewer calories in a
balanced diet will promote health and stimulate weight loss, with significantly better results achieved when combined with regular
exercise.

Health Benefits of Whole Grains in the Diet

While excessive consumption of simple carbohydrates is potentially bad for your health, consuming more complex carbohydrates
is extremely beneficial to health. There is a wealth of scientific evidence supporting that replacing refined grains with whole grains
decreases the risk for obesity, Type 2 diabetes, and cardiovascular disease. Whole grains are great dietary sources of fiber, vitamins,
minerals, healthy fats, and a vast amount of beneficial plant chemicals, all of which contribute to the effects of whole grains on
health. Eating a high-fiber meal as compared to a low-fiber meal (see Figure 4.14) can significantly slow down the absorption
process therefore affecting blood glucose levels. Americans typically do not consume the recommended amount of whole grains,
which is 50 percent or more of grains from whole grains.

Figure : Fibers Role in Carbohydrate Digestion and

Absorption. Image by Allison Calabrese / CC BY 4.0
Diets high in whole grains have repeatedly been shown to decrease weight. A large group of studies all support that consuming
more than two servings of whole grains per day reduces one’s chances of getting Type 2 diabetes by 21 percent.[7] The Nurses’
Health Study found that women who consumed two to three servings of whole grain products daily were 30 percent less likely to
have a heart attack.[8]
The AHA makes the following statements on whole grains[9]:
“Dietary fiber from whole grains, as part of an overall healthy diet, helps reduce blood cholesterol levels and may lower risk of
heart disease.”
“Fiber-containing foods, such as whole grains, help provide a feeling of fullness with fewer calories and may help with weight
management.”

4.4.3 [Link]
 Figure : Grain Consumption Statistics in America. Source: Economic
Research Service. [Link]
characteristics/[Link].

Learning Activities
1. Welsh JA, Sharma AJ, et al. (2011). Consumption of Added Sugars Is Decreasing in the United States. American Journal of
Clinical Nutrition, 94(3), 726–34. [Link] Accessed September 22, 2017. ↵
2. Malik VS, Schulze MB, Hu FB. (2006). Intake of Sugar-Sweetened Beverages and Weight Gain: A Systematic Review.
American Journal of Clinical Nutrition, 84(2), 274–88. [Link]/content/84/2/[Link]. Accessed September 22, 2017. ↵
3. Public Health Takes Aim at Sugar and Salt. Harvard School of Public Health.
[Link] Published 2009. Accessed September 30, 2017. ↵
4. Van Horn L, Johnson RK, et al.(2010). Translation and Implementation of Added Sugars Consumption Recommendations.
Circulation, 122, 2470–[Link]/content/122/23/2470/tab-supplemental. Accessed September 27, 2017. ↵
5. Elliott SS, Keim NL, et al. (2002). Fructose, Weight Gain, and the Insulin Resistance Syndrome. American Journal of Clinical
Nutrition, 76(5),911–22. [Link]/content/76/5/[Link]. Accessed September 27, 2017. ↵
6. Kerksick CM, Wismann-Bunn J, et al. (2010). Changes in Weight Loss, Body Composition, and Cardiovascular Disease Risk
after Altering Macronutrient Distributions During a Regular Exercise Program in Obese Women. The Journal of Nutrition,
9(59). [Link] . Accessed September 27, 2017. ↵
7. de Munter JS, Hu FB, et al. (2007). Whole Grain, Bran, and Germ Intake and Risk of Type 2 Diabetes: A Prospective Cohort
Study and Systematic Review. PLOS Medicine, 4(8), e261. [Link] Accessed
September 27, 2017. ↵
8. Liu S, Stampfer MJ, et al. (1999). Whole-Grain Consumption and Risk of Coronary Heart Disease: Results from the Nurses’
Health Study. American Journal of Clinical Nutrition, 70(3), 412–19. [Link]/content/70/3/[Link]. Accessed
September 27, 2017. ↵
9. Whole Grains and Fiber. American Heart Association.
[Link]
Fiber_UCM_303249_Article.jsp. Updated 2017. Accessed September 30, 2017. ↵

This page titled 4.4: Health Consequences and Benefits of High-Carbohydrate Diets is shared under a CC BY-NC-SA 4.0 license and was
authored, remixed, and/or curated by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to
the style and standards of the LibreTexts platform.
4.4: Health Consequences and Benefits of High-Carbohydrate Diets by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan
Titchenal is licensed CC BY-NC-SA 4.0. Original source: [Link]

4.4.4 [Link]
4.5: Looking Closely at Diabetes
Learning Objectives
Summarize the long-term health implications and the dietary approaches to living with Type 1 and Type 2 diabetes.

Diabetes is one of the top three diseases in America. It affects millions of people and causes tens of thousands of deaths each year.
Diabetes is a metabolic disease of insulin deficiency and glucose over-sufficiency. Like other diseases, genetics, nutrition,
environment, and lifestyle are all involved in determining a person’s risk for developing diabetes. One sure way to decrease your
chances of getting diabetes is to maintain an optimal body weight by adhering to a diet that is balanced in carbohydrate, fat, and
protein intake. There are three different types of diabetes: Type 1 diabetes, Type 2 diabetes, and gestational diabetes.

Type 1 Diabetes
Type 1 diabetes is a metabolic disease in which insulin-secreting cells in the pancreas are killed by an abnormal response of the
immune system, causing a lack of insulin in the body. Its onset typically occurs before the age of thirty. The only way to prevent the
deadly symptoms of this disease is to inject insulin under the skin. Before this treatment was discovered, people with Type 1
diabetes died rapidly after disease onset. Death was the result of extremely high blood-glucose levels affecting brain function and
leading to coma and death. Up until 1921, patients with Type 1 diabetes, the majority of them children, spent their last days in a
ward where they lapsed into a coma awaiting death. One of the most inspiring acts in medical history is that of the scientists who
discovered, isolated, and purified insulin and then went on to find out that it relieved the symptoms of Type 1 diabetes, first in dogs
and then in humans. Frederick Banting, Charles Best, and James Collip went into a hospital ward in Toronto, Canada and injected
comatose children with insulin. Before they completed their rounds children were already awakening to the cheers of their families.
A person with Type 1 diabetes usually has a rapid onset of symptoms that include hunger, excessive thirst and urination, and rapid
weight loss. Because the main function of glucose is to provide energy for the body, when insulin is no longer present there is no
message sent to cells to take up glucose from the blood. Instead, cells use fat and proteins to make energy, resulting in weight loss.
If Type 1 diabetes goes untreated individuals with the disease will develop a life-threatening condition called ketoacidosis. This
condition occurs when the body uses fats and not glucose to make energy, resulting in a build-up of ketone bodies in the blood. It is
a severe form of ketosis with symptoms of vomiting, dehydration, rapid breathing, and confusion and eventually coma and death.
Upon insulin injection these severe symptoms are treated and death is avoided. Unfortunately, while insulin injection prevents
death, it is not considered a cure. Type 1 diabetics are advised to count the carbohydrates they eat, to consume low glycemic index
foods, and to monitor blood sugar levels. These guidelines are aimed at preventing large fluctuations in blood glucose. Type 1
diabetes accounts for between 5 and 10 percent of diabetes cases.

Type 2 Diabetes
The other 90 to 95 percent of diabetes cases are Type 2 diabetes. Type 2 diabetes is defined as a metabolic disease of insulin
insufficiency, but it is also caused by muscle, liver, and fat cells no longer responding to the insulin in the body (Figure ). In
brief, cells in the body have become resistant to insulin and no longer receive the full physiological message of insulin to take up
glucose from the blood. Thus, similar to patients with Type 1 diabetes, those with Type 2 diabetes also have high blood-glucose
levels.
For Type 2 diabetics, the onset of symptoms is more gradual and less noticeable than for Type 1 diabetics. The symptoms are
increased thirst and urination, unexplained weight loss, and hunger. The first stage of Type 2 diabetes is characterized by high
glucose and insulin levels. This is because the insulin-secreting cells in the pancreas attempt to compensate for insulin resistance by
making more insulin. In the second stage of Type 2 diabetes, the insulin-secreting cells in the pancreas become exhausted and die.
At this point, Type 2 diabetics also have to be treated with insulin injections. Healthcare providers is to prevent the second stage
from happening. As with Type 1 diabetes, chronically high-glucose levels cause big detriments to health over time, so another goal
for patients with Type 2 diabetes is to properly manage their blood-glucose levels. The front-line approach for treating Type 2
diabetes includes eating a healthy diet and increasing physical activity.

4.5.1 [Link]
 Figure : Type 2 diabetes
is a metabolic disease characterized by high blood-glucose levels. © Shutterstock
The Centers for Disease Control Prevention (CDC) estimates that as of 2010, 25.8 million Americans have diabetes, which is 8.3
percent of the population. Centers for Disease Control and Prevention. “Diabetes Research and Statistics.” Accessed September 30,
2011. [Link]/diabetes/consumer/[Link]. In 2007 the cost of diabetes to the United States was estimated at $174
[Link] for Disease Control and Prevention. “CDC Statements on Diabetes Issues.” Accessed September 30, 2011.
[Link]/diabetes/news/docs/[Link]. The incidence of Type 2 diabetes has more than doubled in America in the past thirty
years and the rise is partly attributed to the increase in obesity in this country. Genetics, environment, nutrition, and lifestyle all
play a role in determining a person’s risk for Type 2 diabetes. We have the power to change some of the determinants of disease,
but not others. The Diabetes Prevention Trial that studied lifestyle and drug interventions in more than three thousand participants
who were at high risk for Type 2 diabetes found that intensive lifestyle intervention reduced the chances of getting Type 2 diabetes
by 58 %. Knowler, W. C. et al. “Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin.” N Engl J
Med 346, no. 6 (2002): 393–403. [Link]

Video : Do You Have High Blood Sugar?

A more in-depth view of blood sugar and your health.

Denver health clinic - Do You Have Hig…

Hig…

Having more than one risk factor for Type 2 diabetes substantially increases a person’s chances for developing the disease.
Metabolic syndrome refers to a medical condition in which people have three or more risk factors for Type 2 diabetes and
cardiovascular disease (Figure ). According to the International Diabetes Federation (IDF) people are diagnosed with this
syndrome if they have central (abdominal) obesity and any two of the following health parameters: triglycerides greater than 150
mg/dL; high density lipoproteins (HDL) lower than 40 mg/dL; systolic blood pressure above 100 mmHg, or diastolic above 85
mmHg; fasting blood-glucose levels greater than 100 mg/[Link] Diabetes Federation. “The IDF Consensus Worldwide
Definition of the Metabolic Syndrome.” Accessed September 30, 2011. [Link]/webdata/docs/IDF_..._def_final.pdf.

4.5.2 [Link]
 Figure : Metabolic Syndrome: A Combination of Risk Factors Increasing the Chances for Chronic Disease
The IDF estimates that between 20 and 25 percent of adults worldwide have metabolic syndrome. Studies vary, but people with
metabolic syndrome have between a 9 and 30 times greater chance for developing Type 2 diabetes than those who do not have the
[Link] Diabetes Federation. “The IDF Consensus Worldwide Definition of the Metabolic Syndrome.” Accessed
September 30, 2011. [Link]/webdata/docs/IDF_..._def_final.pdf.

Overview of the most significant possible symptoms of diabetes. (Public domain; Mikael Häggström)

Gestational Diabetes
During pregnancy some women develop gestational diabetes. Gestational diabetes is characterized by high blood-glucose levels
and insulin resistance. The exact cause is not known but does involve the effects of pregnancy hormones on how cells respond to
insulin. Gestational diabetes can cause pregnancy complications and it is common practice for healthcare practitioners to screen
pregnant women for this metabolic disorder. The disorder normally ceases when the pregnancy is over, but the National Diabetes
Information Clearing House notes that women who had gestational diabetes have between a 40 and 60 percent likelihood of
developing Type 2 diabetes within the next ten years. National Diabetes Information Clearing House. “Diabetes Overview.”
Accessed September 30, 2011. [Link]/dm/pubs/overview/. Gestational diabetes not only affects the health of a
pregnant woman but also is associated with an increased risk of obesity and Type 2 diabetes in her child.

4.5.3 [Link]
Prediabetes
As the term infers, prediabetes is a metabolic condition in which people have moderately high glucose levels, but do not meet the
criteria for diagnosis as a diabetic. Over seventy-nine million Americans are prediabetic and at increased risk for Type 2 diabetes
and cardiovascular disease. National Diabetes Information Clearing House. “Diabetes Overview.” Accessed September 30, 2011.
[Link]/dm/pubs/overview/. The National Diabetes Information Clearing House reports that 35 percent of adults
aged twenty and older, and 50 percent of those over the age of sixty-five have [Link] Diabetes Information Clearing
House. “Diabetes Overview.” Accessed September 30, 2011. [Link]/dm/pubs/overview/.

Long-Term Health Consequences of Diabetes

The long-term health consequences of diabetes are severe. They are the result of chronically high glucose concentrations in the
blood accompanied by other metabolic abnormalities such as high blood-lipid levels. People with diabetes are between two and
four times more likely to die from cardiovascular disease. Diabetes is the number one cause of new cases of blindness, lower-limb
amputations, and kidney failure. Many people with diabetes develop peripheral neuropathy, characterized by muscle weakness, loss
of feeling and pain in the lower extremities. More recently, there is scientific evidence to suggest people with diabetes are also at
increased risk for Alzheimer’s disease.

Video : Diabetes and Associated Complications

Watch this video to learn more about the whole-body complications associated with diabetes.

Diabetes Treatment
Keeping blood-glucose levels in the target range (70–130 mg/dL before a meal) requires careful monitoring of blood-glucose levels
with a blood-glucose meter, strict adherence to a healthy diet, and increased physical activity. Type 1 diabetics begin insulin
injections as soon as they are diagnosed. Type 2 diabetics may require oral medications and insulin injections to maintain blood-
glucose levels in the target range. The symptoms of high blood glucose, also called hyperglycemia, are difficult to recognize,
diminish in the course of diabetes, and are mostly not apparent until levels become very high. The symptoms are increased thirst
and frequent urination. Having too low blood glucose levels, known as hypoglycemia, is also detrimental to health. Hypoglycemia
is more common in Type 1 diabetics and is most often caused by injecting too much insulin or injecting it at the wrong time. The
symptoms of hypoglycemia are more acute including shakiness, sweating, nausea, hunger, clamminess, fatigue, confusion,
irritability, stupor, seizures, and coma. Hypoglycemia can be rapidly and simply treated by eating foods containing about ten to
twenty grams of fast-releasing carbohydrates. If symptoms are severe a person is either treated by emergency care providers with
an intravenous solution of glucose or given an injection of glucagon, which mobilizes glucose from glycogen in the liver. Some
people who are not diabetic may experience reactive hypoglycemia. This is a condition in which people are sensitive to the intake
of sugars, refined starches, and high GI foods. Inviduals with reactive hypoglycemia have some symptoms of hypoglycemia.
Symptoms are caused by a higher than normal increase in blood-insulin levels. This rapidly decreases blood-glucose levels to a
level below what is required for proper brain function.

4.5.4 [Link]
 Insulin Syringe and Pen. (CC-SA-BY-3.0; BruceBlaus)
The major determinants of Type 2 diabetes that can be changed are overnutrition and a sedentary lifestyle. Therefore, reversing or
improving these factors by lifestyle interventions markedly improve the overall health of Type 2 diabetics and lower blood-glucose
levels. In fact it has been shown that when people are overweight, losing as little as nine pounds (four kilograms) decreases blood-
glucose levels in Type 2 diabetics. The Diabetes Prevention Trial demonstrated that by adhering to a diet containing between 1,200
and 1,800 kilocalories per day with a dietary fat intake goal of less than 25 percent and increasing physical activity to at least 150
minutes per week, people at high risk for Type 2 diabetes achieved a weight loss of 7 percent and significantly decreased their
chances of developing Type 2 [Link], W. C. et al. “Reduction in the Incidence of Type 2 Diabetes with Lifestyle
Intervention or Metformin.” N Engl J Med 346, no. 6 (2002): 393–403. [Link]
The American Diabetes Association (ADA) has a website that provides information and tips for helping diabetics answer the
question, “What Can I Eat” (see Note 4.34). In regard to carbohydrates the ADA recommends diabetics keep track of the
carbohydrates they eat and set a limit. These dietary practices will help keep blood-glucose levels in the target range.

Interactive

The ADA has a website containing great information and tips on how to eat a healthy diet that helps keep blood-glucose levels
in the target range. Visit it to learn more on how to prevent serious complications of this disease.
[Link]
DropDownFF&utm_content=WhatCanIEat&utm_campaign=CON

An unfortunate problem is that most diabetics do not adhere to the lifestyle interventions long-term. This is partly because of
individual disinclination, but is also because health insurance companies do not provide continued financial support for dietary
guidance and because primary care physicians do not prescribe dietary guidance from a dietitian. This shifts the way diabetes is
treated away from lifestyle intervention toward medications, as the goal still remains to manage blood-glucose levels. Numerous
oral medications are available on the market and are often prescribed to Type 2 diabetics in combination.

Key Takeaways
Diabetes is a disease of insulin deficiency and glucose oversufficiency. Like other diseases, genetics, nutrition, environment,
and lifestyle are all involved in determining a person’s risk for developing diabetes.
Type 1 diabetes was once a death sentence, but now can be treated with insulin injections. However, insulin injections do not
cure the disease, and diabetics can suffer many disease complications. Diabetes complications can be relieved by strictly
managing blood-glucose levels, adhering to a healthy diet, and increasing physical activity.
The incidence of Type 2 diabetes has more than doubled in America in the past thirty years and the rise is partly attributed to the
increase in obesity. The front-line approach for treating Type 2 diabetes includes eating a healthy diet and increasing physical
activity.
The long-term health consequences of diabetes are severe. They are the result of chronically high glucose concentrations in the
blood and other metabolic abnormalities such as high blood-lipid levels.

4.5.5 [Link]
Discussion Starters
1. If you owned a grocery store what are some practices you could introduce to combat the epidemic of Type 2 diabetes in this
country?
2. What are some options for you to intervene in your lifestyle and decrease your risk for Type 2 diabetes?

4.5: Looking Closely at Diabetes is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

4.5.6 [Link]
4.6: Carbohydrates and Personal Diet Choices
In this chapter, you learned what carbohydrates are, the different types of carbohydrates in your diet, and that excess consumption
of some types of carbohydrates cause disease while others decrease disease risk. Now that we know the benefits of eating the right
carbohydrate, we will examine exactly how much should be eaten to promote health and prevent disease.

How Many Carbohydrates Does a Person Need?

The Food and Nutrition Board of IOM has set the Recommended Dietary Allowance (RDA) of carbohydrates for children and
adults at 130 grams per day. This is the average minimum amount the brain requires to function properly. The Acceptable
Macronutrient Distribution Range (AMDR) for carbohydrates is between 45 and 65 percent of your total caloric daily intake. This
means that on a 2,000 kilocalorie diet, a person should consume between 225 and 325 grams of carbohydrate each day. According
to the IOM not more than 25 percent of total calories consumed should come from added sugars. The World Health Organization
and the AHA recommend much lower intakes of added sugars—10 percent or less of total calories consumed. The IOM has also set
Adequate Intakes for dietary fiber, which are 38 and 25 grams for men and women, respectively. The recommendations for dietary
fiber are based upon the intake levels known to prevent against heart disease.
Table Dietary Reference Intakes For Carbohydrates And Fiber

Carbohydrate Type RDA (g/day) AMDR (% calories)

Total Carbohydrates 130 45–65

Added Sugars < 25

Fiber 38 (men),* 25 (women)*

* denotes Adequate Intake

Dietary Sources of Carbohydrates

Carbohydrates are contained in all five food groups: grains, fruits, vegetables, meats, beans (only in some processed meats and
beans), and dairy products. Fast-releasing carbohydrates are more prevalent in fruits, fruit juices, and dairy products, while slow-
releasing carbohydrates are more plentiful in starchy vegetables, beans, and whole grains. Fast-releasing carbohydrates are also
found in large amounts in processed foods, soft drinks, and sweets. On average, a serving of fruits, whole grains, or starches
contains 15 grams of carbohydrates. A serving of dairy contains about 12 grams of carbohydrates, and a serving of vegetables
contains about 5 grams of carbohydrates. Table 4.3 gives the specific amounts of carbohydrates, fiber, and added sugar of various
foods.
Table : Carbohydrates in Foods (grams/serving)

4.6.1 [Link]
 Foods Total Carbohydrates Sugars Fiber Added Sugars

Banana 27 (1 medium) 14.40 3.1 0

Lentils 40 (1 c.) 3.50 16.0 0

Snap beans 8.7 (1 c.) 1.60 4.0 0

Green pepper 5.5 (1 medium) 2.90 2.0 0

Corn tortilla 10.7 (1) 0.20 1.5 0

Bread, wheat bran 17.2 (1 slice) 3.50 1.4 3.4

Bread, rye 15.5 (1 slice) 1.20 1.9 1.0

Bagel (plain) 53 (1 medium) 5.30 2.3 4.8

Brownie 36 (1 square) 20.50 1.2 20.0

Oatmeal cookie 22.3 (1 oz.) 12.00 2.0 7.7

Cornflakes 23 (1 c.) 1.50 0.3 1.5

Pretzels 47 (10 twists) 1.30 1.7 0

Popcorn (homemade) 58 (100 g) 0.50 10.0 0

Skim milk 12 (1 c.) 12.00 0 0

Cream (half and half) 0.65 (1 Tbs.) 0.02 0 0

Cream substitute 1.0 (1 tsp.) 1.00 0 1.0

Cheddar cheese 1.3 (1 slice) 0.50 0 0

Yogurt (with fruit) 32.3 (6 oz.) 32.30 0 19.4

Caesar dressing 2.8 (1 Tbs.) 2.80 0 2.4

Sources:
National Nutrient Database for Standard Reference. US Department of Agriculture.
[Link] Updated December 7, 2011. Accessed September 17, 2017.
Database for the Added Sugars Content of Selected Foods. US Department of Agriculture.
[Link] Published February 2006. Accessed September 27, 2017.

It’s the Whole Nutrient Package

In choosing dietary sources of carbohydrates the best ones are those that are nutrient dense, meaning they contain more essential
nutrients per calorie of energy. In general, nutrient-dense carbohydrates are minimally processed and include whole-grain breads
and cereals, low-fat dairy products, fruits, vegetables, and beans. In contrast, empty-calorie carbohydrate foods are highly
processed and often contain added sugars and fats. Soft drinks, cakes, cookies, and candy are examples of empty-calorie
carbohydrates. They are sometimes referred to as ‘bad carbohydrates,’ as they are known to cause health problems when consumed
in excess.

Understanding Carbohydrates from Product Information

While nutrition facts labels aid in determining the amount of carbohydrates you eat, they do not help in determining whether a food
is refined or not. The ingredients list provides some help in this regard. It identifies all of the food’s ingredients in order of
concentration, with the most concentrated ingredient first. When choosing between two breads, pick the one that lists whole wheat
(not wheat flour) as the first ingredient, and avoid those with other flour ingredients, such as white flour or corn flour. (Enriched

4.6.2 [Link]
wheat flour refers to white flour with added vitamins.) Eat less of products that list HFCS and other sugars such as sucrose, honey,
dextrose, and cane sugar in the first five ingredients. If you want to eat less processed foods then, in general, stay away from
products with long ingredient lists. On the front of food and beverages the manufacturers may include claims such as “sugar-free,”
“reduced sugar,” “high fiber,” etc.. The Nutrition and Labeling Act of 1990 has defined for the food industry and consumers what
these labels mean (Table ).
Table : Food Labels Pertaining to Carbohydrates

Label Meaning

Sugar-free Contains less than 0.5 grams of sugar per serving

Reduced sugar Contains 25 percent less sugar than similar product

Contains 25 percent less sugar than similar product, and was not
Less sugar
altered by processing to become so

No sugars added No sugars added during processing

High fiber Contains at least 20 percent of daily value of fiber in each serving

Contains between 10 and 19 percent of the daily value of fiber per

A good source of fiber
serving

More fiber Contains 10 percent or more of the daily value of fiber per serving

Source: Appendix A: Definitions of Nutrient Claims. Guidance for Industry: A Food Labeling Guide. US Food and Drug
Administration.
[Link]/Food/GuidanceComplianceRegulatoryInformation/GuidanceDocuments/FoodLabelingNutrition/FoodLabelingGuide/
[Link]. Updated October 2009. Accessed September 22, 2017.
In addition, the FDA permits foods that contain whole oats (which contain soluble fiber) to make the health claim on the package
that the food reduces the risk of coronary heart disease. The FDA no longer permits Cheerios to make the claim that by eating their
cereal “you can lower your cholesterol four percent in six weeks.”

Personal Choices
Carbohydrates are in most foods so you have a great variety of choices with which to meet the carbohydrates recommendations for
a healthy diet. The 2010 Dietary Guidelines recommends eating more unrefined carbohydrates and more fiber, and reducing
consumption of foods that are high in added sugars. To accomplish these recommendations use some or all of the following
suggestions:
Get more daily carbohydrate servings from whole grains by eating a whole-grain cereal for breakfast, using whole-grain bread
to make a sandwich for lunch, and eating a serving of beans and/or nuts with dinner.
Make sure to get at least three servings (or more) of all the grains you eat as whole grains every day. A serving of whole grains
is equal to one slice of whole-wheat bread, one ounce of whole-grain cereal, and one-half cup of cooked cereal, brown rice, or
whole-wheat pasta.
Food products made with cornmeal use the whole grain so choose tortillas, corn cereals, and corn breads with cornmeal listed as
the first ingredient.
When baking, substitute whole-wheat flour or other whole-grain flour for some of the refined white flour.
If you like bread at dinner, choose a whole-grain muffin over a Kaiser roll or baguette.
Add beans, nuts, or seeds to salad—they add texture and taste.
Choose whole-grain pastas and brown rice, cook al dente, and add some beans and vegetables in equal portions.
Change it up a bit and experience the taste and satisfaction of other whole grains such as barley, quinoa, and bulgur.
Eat snacks high in fiber, such as almonds, pistachios, raisins, and air-popped popcorn.
Add an artichoke and green peas to your dinner plate more often.
Calm your “sweet tooth” by eating fruits, such as berries or an apple.

4.6.3 [Link]
 Replace sugary soft drinks with seltzer water, tea, or a small amount of 100 percent fruit juice added to water or soda water.

The Food Industry: Functional Attributes of Carbohydrates and the Use of Sugar Substitutes
In the food industry, both fast-releasing and slow-releasing carbohydrates are utilized to give foods a wide spectrum of functional
attributes, including increased sweetness, viscosity, bulk, coating ability, solubility, consistency, texture, body, and browning
capacity. The differences in chemical structure between the different carbohydrates confer their varied functional uses in foods.
Starches, gums, and pectins are used as thickening agents in making jam, cakes, cookies, noodles, canned products, imitation
cheeses, and a variety of other foods. Molecular gastronomists use slow-releasing carbohydrates, such as alginate, to give shape
and texture to their fascinating food creations. Adding fiber to foods increases bulk. Simple sugars are used not only for adding
sweetness, but also to add texture, consistency, and browning. In ice cream, the combination of sucrose and corn syrup imparts
sweetness as well as a glossy appearance and smooth texture.
Due to the potential health consequences of consuming too many added sugars, sugar substitutes have replaced them in many foods
and beverages. Sugar substitutes may be from natural sources or artificially made. Those that are artificially made are called
artificial sweeteners and must be approved by the FDA for use in foods and beverages. The artificial sweeteners approved by the
FDA are saccharin, aspartame, acesulfame potassium, neotame, advantame, and sucralose. Stevia is an example of a naturally
derived sugar substitute. It comes from a plant commonly known as sugarleaf and does not require FDA approval. Sugar alcohols,
such as xylitol, sorbitol, erythritol, and mannitol, are sugar alcohols that occur naturally in some fruits and vegetables. However,
they are industrially synthesized with yeast and other microbes for use as food additives. The FDA requires that foods disclose the
fact that they contain sugar alcohols, but does not require scientific testing of it. (Though many of them have undergone studies
anyway.) In comparison to sucrose, artificial sweeteners are significantly sweeter (in fact, by several hundred times), but sugar
alcohols are more often less sweet than sucrose (see Table 4.5). Artificial sweeteners and Stevia are not digested or absorbed in
significant amounts and therefore are not a significant source of calories in the diet. Sugar alcohols are somewhat digested and
absorbed and, on average, contribute about half of the calories as sucrose (4 kilocalories/gram). These attributes make sugar
substitutes attractive for many people—especially those who want to lose weightand/or better manage their blood-glucose levels.
Table : Relative Sweetness Of Sugar Substitutes

Sweetener Trade Names Sweeter than Sucrose (times)

Saccharine “Sweet-N-Lo” 300.0

Aspartame “NutraSweet,” “Equal” 80-200.0

Acesulfame-K “Sunette” 200.0

Neotame 7,000.0–13,000.0

Advantame 20,000

Sucralose “Splenda” 600.0

Stevia 250.0–300.0

Xylitol 0.8

Mannitol 0.5

Sorbitol 0.6

Erythritol 1.0

Benefits of Sugar Substitutes

Consuming foods and beverages containing sugar substitutes may benefit health by reducing the consumption of simple sugars,
which are higher in calories, cause tooth decay, and are potentially linked to chronic disease. Artificial sweeteners are basically
non-nutrients though not all are completely calorie-free. However, because they are so intense in sweetness they are added in very
small amounts to foods and beverages. Artificial sweeteners and sugar alcohols are not “fermentable sugars” and therefore they do

4.6.4 [Link]
not cause tooth decay. Chewing gum with artificial sweeteners is the only proven way that artificial sweeteners promote oral health.
The American Dental Association (ADA) allows manufacturers of chewing gum to label packages with an ADA seal if they have
convincing scientific evidence demonstrating their product either reduces plaque acids, cavities, or gum disease, or promotes tooth
remineralization.
There is limited scientific evidence that consuming products with artificial sweeteners decreases weight. In fact, some studies
suggest the intense sweetness of these products increases appetite for sweet foods and may lead to increased weight gain. Also,
there is very limited evidence that suggests artificial sweeteners lower blood-glucose levels. Additionally, many foods and
beverages containing artificial sweeteners and sugar alcohols are still empty-calorie foods (i.e. chewing sugarless gum or drinking
diet soda pop) are not going to better your blood-glucose levels or your health.

Health Concerns
The most common side effect of consuming products containing sugar substitutes is gastrointestinal upset, a result of their
incomplete digestion. Since the introduction of sugar substitutes to the food and beverage markets, the public has expressed
concern about their safety. The health concerns of sugar substitutes originally stemmed from scientific studies, which were
misinterpreted by both scientists and the public.
In the early 1970s scientific studies were published that demonstrated that high doses of saccharin caused bladder tumors in rats.
This information fueled the still-ongoing debate of the health consequences of all artificial sweeteners. In actuality, the results from
the early studies were completely irrelevant to humans. The large doses (2.5 percent of diet) of saccharine caused a pellet to form in
the rat’s bladder. That pellet chronically irritated the bladder wall, eventually resulting in tumor development. Since this study,
scientific investigation in rats, monkeys, and humans have not found any relationship between saccharine consumption and bladder
cancer. In 2000, saccharin was removed from the US National Toxicology Program’s list of potential carcinogens.[1]
There have been health concerns over other artificial sweeteners, most notably aspartame (sold under the trade names of
NutraSweet and Equal). The first misconception regarding aspartame was that it was linked with an increase in the incidence of
brain tumors in the United States. It was subsequently discovered that the increase in brain tumors started eight years prior to the
introduction of aspartame to the market. Today, aspartame is accused of causing brain damage, autism, emotional disorders, and a
myriad of other disorders and diseases. Some even believe aspartame is part of a governmental conspiracy to make people dumber.
The reality is there is no good scientific evidence backing any of these accusations, and that aspartame has been the most
scientifically tested food additive. It is approved for use as an artificial sweetener in over ninety countries.
Aspartame is made by joining aspartic acid and phenylalanine to a dipeptide (with a methyl ester). When digested, it is broken
down to aspartic acid, phenylalanine, and methanol. People who have the rare genetic disorder phenylketonuria (PKU) have to
avoid products containing aspartame. Individuals who have PKU do not have a functional enzyme that converts phenylalanine to
the amino acid tyrosine. This causes a buildup of phenylalanine and its metabolic products in the body. If PKU is not treated, the
buildup of phenylalanine causes progressive brain damage and seizures. The FDA requires products that contain aspartame to state
on the product label, “Phenylketonurics: Contains Phenylalanine.” For more details on sugar substitutes please refer to Table .
Table : Sweeteners

4.6.5 [Link]
Sweeteners with Consumer
Calories Source/Origin Controversial Issues Product Uses
Trade Name Recommendations

FDA set maximum

Acceptable Daily
Composed of two Intakes (ADI):50 Children have
amino acids mg/kg body weight potential to reach
(phenylalanine + = 16 12 oz. diet soft ADI if consuming
Aspartame Beverages, gelatin
aspartic acid) + drinks for adults. many beverages,
NutraSweet 4 kcal/g desserts, gums, fruit
[Link] *Cannot be used in desserts, frozen
Equal spreads.
hundred times products requiring desserts, and gums
sweeter than cooking. containing
sucrose. People with PKU aspartame routinely.
should not consume
aspartame.

1970s, high doses of

saccharin associated
with bladder cancer
in laboratory
animals. In 1977,
FDA proposed
banning saccharin
from use in food General purpose
Discovered in 1878. protest launched sweetener in all
The basic substance by consumer & foods and
is benzoic ADI: 5 mg/kg body interest groups [Link] as
Saccharin
0 kcal/g [Link] weight.*Can be warning label Sweet ‘n’ Low in
Sweet ‘n’ Low
hundred times used in cooking. listed on United States; also
sweeter than products about found in cosmetics
sucrose. saccharin and and pharmaceutical
cancer risk in products.
animals until
2001 when
studies
concluded that it
did not cause
cancer in
humans

Acesulfame K 0 kcal/g Discovered in 1967. ADI: 15 mg/kg Chewing gum,

Sunnette Composed of an body [Link] powdered beverage
Sweet One organic salt, cannot digest it. mixes, nondairy
potassium (K). *Can be used in creamers, gelatins,
Structure is very cooking. puddings, instant
similar to teas and coffees.
saccharin’[Link] passes
through the body
unchanged which
means it does not
provide energy.
Two hundred times
sweeter than

4.6.6 [Link]
Sweeteners with Consumer
Calories Source/Origin Controversial Issues Product Uses
Trade Name Recommendations
sucrose.

1949, cyclamate
approved by FDA
for use. Cyclamate
was classified as
GRAS (Generally
Recognized As
Safe) until 1970
when it was
removed from
GRAS status and
banned from use in
Thirty times sweeter all food and Recommended as a
Cyclamates than beverage products substitute for table
0 kcal/g No ADI available.
Sugar Twin [Link] within the United sugar for diabetics in
in 1937. States on the basis 1950s, baked goods.
of one study that
indicated it caused
bladder cancer in
rats. Approval still
pending for use in
the United States
since the
[Link] and
other countries use
this type of
sweetener.

General purpose
First discovered in sweetener, baked
1976. Approved for goods, beverages,
use in 1998 in the gelatin desserts,
United States and in frozen dairy
1991 in desserts, canned
1 Splenda packet [Link] ADI: 5 mg/kg body fruits, salad
Sucralose
contains 3.31 from sucrose in weight.*Can be dressings, dietary
Splenda
calories = 1g which three of its used in cooking. supplements;
hydroxyl (OH) currently
groups are replaced recommended as a
by chlorine (Cl−). replacement for
Six hundred times table sugar and
sweeter than sugar. additive for
diabetics.

Stevioside N/A Derived from stevia Classified as Used sparingly, Sold in health food
Stevia plant found in South [Link] stevia may do little stores as a dietary
Sweet Leaf America. Stevia to be a dietary harm, but FDA supplement.
rebaudiana leaves. supplement and could not approve
approved not as an extensive use of this
sweetener due to

4.6.7 [Link]
Sweeteners with Consumer
Calories Source/Origin Controversial Issues Product Uses
Trade Name Recommendations
additive, but as a concerns regarding
dietary supplement. its effect on
reproduction, cancer
development, and
energy metabolism.

It is illegal to sell
true raw sugar in the
United States
because when raw it Over-consumption
contains dirt and has been linked to
Extracted from insect parts, as well several health Biscuits, cookies,
either sugar beets or as other byproducts. effects such as tooth cakes, pies, candy
Sucrose
~4 kcal/g sugar cane, which is Raw sugar products decay or dental canes, ice cream,
Sugar
then purified and sold in the United caries and sorbets, and as a
crystallized. States have actually contributes to food preservative.
gone through more increased risk for
than half of the chronic diseases.
same steps in the
refining process as
table sugar.

*Considered safe
for baking and
[Link]
under twelve
months old should
Made from sucrose.
not be given honey
Contains nectar of
because their
flowering plants. Sweeteners in
digestive tracts
Made by bees. various foods and
cannot handle the
Sucrose is fructose beverages such as
Honey 3 kcal/g bacteria found in
+ glucose; however, sodas, teas,
honey. Older
honey contains alcoholic beverages,
children and adults
more calories than and baked goods.
are immune to these
sucrose because
effects. Honey
honey is denser.
contains some
harmful bacteria
that can cause fatal
food poisoning in
infants.

HFCS Dry form: 4 kcal/g; Corn is milled to Controversial Soft drinks, desserts,
high fructose Liquid form: 3 produce corn starch, because it is found candies, jellies.
corn syrup kcal/g then the cornstarch ubiquitously in
is further processed processed food
to yield corn syrup. products, which
could lead to
overconsumption.
Study results are
varied regarding its

4.6.8 [Link]
 Sweeteners with Consumer
Calories Source/Origin Controversial Issues Product Uses
Trade Name Recommendations
role in chronic
disease.

Provide bulk and

sweetness in the
Less likely to cause
Sugar Alcohols Sugar May cause diarrhea following sugar-free
tooth decay than
Sorbitol 2–4 kcal/[Link] [Link] is and gastrointestinal items: cookies, jams,
[Link]
Xylitol calorie free derived from distress if consumed jellies, chewing
alcohols have a
Mannitol glucose. in large amounts. gum, candies, mints,
laxative effect.
pharmaceutical and
oral health products.

Regulation
Prior to introducing any new artificial sweetener into foods it is rigorously tested and must be legally approved by the FDA. The
FDA regulates artificial sweeteners along with other food additives, which number in the thousands. The FDA is responsible for
determining whether a food additive presents “a reasonable certainty of no harm” to consumers when used as proposed. The FDA
uses the best scientific evidence available to make the statement of no harm, but it does declare that science has its limits and that
the “FDA can never be absolutely certain of the absence of any risk from the use of any substance.”[2]
The FDA additionally has established ADIs for artificial sweeteners. The ADIs are the maximum amount in milligrams per
kilogram of body weight considered safe to consume daily (mg/kg bw/day) and incorporates a large safety factor. The following list
contains the artificial sweeteners approved for use in foods and beverages in the United States, and their ADIs:
Acesulfame potassium (Sunett, Sweet One). ADI = 15 mg/kg bw/day
Aspartame (Equal, NutraSweet). ADI = 50 mg/kg bw/day
Neotame. ADI = 18 mg/kg bw/day
Saccharin (SugarTwin, Sweet’N Low). ADI = 5 mg/kg bw/day
Sucralose (Splenda). ADI = 5 mg/kg bw/day

Resources
1. Artificial Sweeteners and Cancer. National Cancer Institute. [Link]
sweeteners. Updated August 5, 2009. Accessed September 22, 2017. ↵
2. Overview of Food Ingredients, Additives and Colors. US Food and Drug Administration. [Link]
[Link]/7993/20170722025446/[Link]
htm. Updated April 2010. Accessed September 22, 2017. ↵

This page titled 4.6: Carbohydrates and Personal Diet Choices is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or
curated by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
4.5: Carbohydrates and Personal Diet Choices by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-
NC-SA 4.0. Original source: [Link]

4.6.9 [Link]
4.7: The Food Industry- Functional Attributes of Carbohydrates and the Use of Sugar
Substitutes
Learning Objectives
Discuss the usefulness (or lack thereof) of consuming foods containing sugar substitutes

In the food industry, both fast-releasing and slow-releasing carbohydrates are utilized to give foods a wide spectrum of functional
attributes, including increased sweetness, viscosity, bulk, coating ability, solubility, consistency, texture, body, and browning
capacity. The differences in chemical structure between the different carbohydrates confer their varied functional uses in foods.
Starches, gums, and pectins are used as thickening agents in making jam, cakes, cookies, noodles, canned products, imitation
cheeses, and a variety of other foods. Molecular gastronomists use slow-releasing carbohydrates, such as alginate, to give shape
and texture to their fascinating food creations (Video ). Adding fiber to foods increases bulk. Simple sugars are used not only
for adding sweetness, but also to add texture, consistency, and browning. In ice cream, the combination of sucrose and corn syrup
imparts sweetness as well as a glossy appearance and smooth texture. Added sugars include white, brown, and raw sugar, corn
syrup, HFCS, malt and maple syrups, liquid fructose, honey, molasses, agave nectar, and crystal dextrose.

Video : Ferran Adrian Demonstrates Alginates

Watch this video to see how molecular gastronomist Ferran Adrian uses the polysaccharide alginate to give shape and texture
to olive puree.

Ferran Adrian Demonstrates Alginates

Due to the potential health consequences of consuming too many added sugars, sugar substitutes have replaced them in many foods
and beverages. Sugar substitutes may be from natural sources or artificially made. Those that are artificially made are called
artificial sweeteners and must be approved by the FDA for use in foods and beverages. The artificial sweeteners approved by the
FDA are saccharin, aspartame, acesulfame potassium, neotame, and sucralose. Stevia is an example of a naturally derived sugar
substitute. It comes from a plant commonly known as sugarleaf and does not require FDA approval. Sugar alcohols, such as xylitol,
sorbitol, erythritol, and mannitol, are carbohydrates that occur naturally in some fruits and vegetables. However, they are
industrially synthesized with yeast and other microbes for use as food additives.

4.7.1 [Link]
 Figure : Pectin (a carbohydrate) is added to jam to give it its
consistency. (bottom) This drawing depicts a pectin molecule. These molecules combine to form the network responsible for
making jelly. (CC BY-SA 3.0; PatríciaR).
The FDA requires that foods disclose the fact that they contain sugar alcohols, but does not require scientific testing of it. (Though
many of them have undergone studies anyway.) In comparison to sucrose, artificial sweeteners are significantly sweeter (in fact, by
several hundred times), but sugar alcohols are more often less sweet than sucrose (Table ). Artificial sweeteners and Stevia are
not digested or absorbed in significant amounts and therefore are not a significant source of calories in the diet. Sugar alcohols are
somewhat digested and absorbed and, on average, contribute about half of the calories as sucrose (4 kilocalories/gram). These
attributes make sugar substitutes attractive for many people—especially those who want to lose weight and/or better manage their
blood-glucose levels.
Table : Sweetness Comparison of Sugar Substitutes

Sweetener Trade Names Times that of Sucrose

Saccharine “Sweet-N-Lo” 600.0

Aspartame “NutraSweet,” “Equal” 180.0–220.0

Acesulfame-K “Sunette” 200.0

Neotame 7,000.0–13,000.0

Sucralose “Splenda” 600.0

Stevia 250.0–300.0

Xylitol 0.8

Mannitol 0.5

Sorbitol 0.6

Erythritol 1.0

Sources: University of North Texas. “Sugar Substitutes.” Accessed November 6, 2012.

[Link]/nutrition/nutrition_brochures/Sugar%[Link], and Yale-New Haven Hospital. “Eat Any Sugar Alcohol
Lately?” Accessed November 6, 2012. [Link]

4.7.2 [Link]
Benefits of Sugar Substitutes
Consuming foods and beverages containing sugar substitutes may benefit health by reducing the consumption of simple sugars,
which are higher in calories, cause tooth decay, and are potentially linked to chronic disease. Artificial sweeteners are basically
nonnutrients though not all are completely calorie-free. However, because they are so intense in sweetness they are added in very
small amounts to foods and beverages. Artificial sweeteners and sugar alcohols are not “fermentable sugars” and therefore they do
not cause tooth decay. Chewing gum with artificial sweeteners is the only proven way that artificial sweeteners promote oral health.
The American Dental Association (ADA) allows manufacturers of chewing gum to label packages with an ADA seal if they have
convincing scientific evidence demonstrating their product either reduces plaque acids, cavities, or gum disease, or promotes tooth
remineralization.
There is limited scientific evidence that consuming products with artificial sweeteners decreases weight. In fact, some studies
suggest the intense sweetness of these products increases appetite for sweet foods and may lead to increased weight gain. Also,
there is very limited evidence that suggests artificial sweeteners lower blood-glucose levels. Additionally, many foods and
beverages containing artificial sweeteners and sugar alcohols are still empty-calorie foods (i.e. chewing sugarless gum or drinking
diet soda pop) are not going to better your blood-glucose levels or your health.

Health Concerns
The most common side effect of consuming products containing sugar substitutes is gastrointestinal upset, a result of their
incomplete digestion. Since the introduction of sugar substitutes to the food and beverage markets, the public has expressed
concern about their safety. The health concerns of sugar substitutes originally stemmed from scientific studies, which were
misinterpreted by both scientists and the public.
In the early 1970s scientific studies were published that demonstrated that high doses of saccharine caused bladder tumors in rats.
This information fueled the still-ongoing debate of the health consequences of all artificial sweeteners. In actuality, the results from
the early studies were completely irrelevant to humans. The large doses (2.5 percent of diet) of saccharine caused a pellet to form in
the rat’s bladder. That pellet chronically irritated the bladder wall, eventually resulting in tumor development. Since this study,
scientific investigation in rats, monkeys, and humans have not found any relationship between saccharine consumption and bladder
cancer. In 2000, saccharin was removed from the US National Toxicology Program’s list of potential [Link] Cancer
Institute. “Artificial Sweeteners and Cancer.” Accessed September 30, 2011.
[Link]
There have been health concerns over other artificial sweeteners, most notably aspartame (sold under the trade names of
NutraSweet and Equal). The first misconception regarding aspartame was that it was linked with an increase in the incidence of
brain tumors in the United States. It was subsequently discovered that the increase in brain tumors started eight years prior to the
introduction of aspartame to the market. Today, aspartame is accused of causing brain damage, autism, emotional disorders, and a
myriad of other disorders and diseases. Some even believe aspartame is part of a governmental conspiracy to make people dumber.
The reality is there is no good scientific evidence backing any of these accusations, and that aspartame has been the most
scientifically tested food additive. It is approved for use as an artificial sweetener in over ninety countries.
Aspartame is made by joining aspartic acid and phenylalanine to amino acids. When digested, it is broken down to aspartic acid,
phenylalanine, and methanol. People who have the rare genetic disorder phenylketonuria (PKU) have to avoid products containing
aspartame. Individuals who have PKU do not have a functional enzyme that converts phenylalanine to the amino acid tyrosine.
This causes a build-up of phenylalanine and its metabolic products in the body. If PKU is not treated, the build-up of phenylalanine
causes progressive brain damage and seizures. The FDA requires products that contain aspartame to state on the product label,
“Phenylketonurics: Contains Phenylalanine.” For more details on sugar substitutes please refer to Table .
Table : Sweeteners

4.7.3 [Link]
Sweeteners with Consumer Controversial
Calories Source/Origin Product Uses
Trade Name Recommendations Issues

FDA set maximum

Acceptable Daily
Intakes (ADI):
Composed of two Children have
50 mg/kg body
amino acids potential to reach
weight = 16 12 oz.
(phenylalanine + ADI if consuming
Aspartame diet soft drinks for Beverages, gelatin
aspartic acid) + many beverages,
NutraSweet 4 kcal/g adults. desserts, gums, fruit
methanol. desserts, frozen
Equal *Cannot be used in spreads.
Two hundred times desserts, and gums
products requiring
sweeter than containing
cooking.
sucrose. aspartame routinely.
People with PKU
should not consume
aspartame.

1970s, high doses of

saccharin associated
with bladder cancer
in laboratory
animals. In 1977,
FDA proposed
banning saccharin
from use in food General purpose
protest launched sweetener in all
Discovered in 1878.
by consumer & foods and beverages.
The basic substance ADI: 5 mg/kg body
interest groups Sold as Sweet ‘n’
Saccharin is benzoic sulfinide. weight.
0 kcal/g warning label Low in United
Sweet ‘n’ Low Three hundred *Can be used in
listed on States; also found in
times sweeter than cooking.
products about cosmetics and
sucrose.
saccharin and pharmaceutical
cancer risk in products.
animals until
2001 when
studies
concluded that it
did not cause
cancer in
humans

Acesulfame K 0 kcal/g Discovered in 1967. ADI: 15 mg/kg Chewing gum,

Sunnette Composed of an body weight. powdered beverage
Sweet One organic salt, Body cannot digest mixes, nondairy
potassium (K). it. creamers, gelatins,
Structure is very *Can be used in puddings, instant
similar to cooking. teas and coffees.
saccharin’s.
It passes through the
body unchanged
which means it does
not provide energy.

4.7.4 [Link]
Sweeteners with Consumer Controversial
Calories Source/Origin Product Uses
Trade Name Recommendations Issues
Two hundred times
sweeter than
sucrose.

1949, cyclamate
approved by FDA
for use. Cyclamate
was classified as
GRAS (Generally
Recognized As
Safe) until 1970
when it was
removed from
GRAS status and
banned from use in
Recommended as a
Cyclamates Thirty times sweeter all food and
substitute for table
Sugar Twin 0 kcal/g than sucrose. No ADI available. beverage products
sugar for diabetics in
(Canada only) Discovered in 1937. within the United
1950s, baked goods.
States on the basis
of one study that
indicated it caused
bladder cancer in
rats. Approval still
pending for use in
the United States
since the ban.
Canada and other
countries use this
type of sweetener.

General purpose
First discovered in sweetener, baked
1976. Approved for goods, beverages,
use in 1998 in the gelatin desserts,
United States and in frozen dairy
1991 in Canada. desserts, canned
ADI: 5 mg/kg body
1 Splenda packet Derived from fruits, salad
Sucralose weight.
contains 3.31 sucrose in which dressings, dietary
Splenda *Can be used in
calories = 1g three of its hydroxyl supplements;
cooking.
(OH) groups are currently
replaced by chlorine recommended as a
(Cl−). replacement for
Six hundred times table sugar and
sweeter than sugar. additive for
diabetics.

Stevioside N/A Derived from stevia Classified as GRAS. Used sparingly, Sold in health food
Stevia plant found in South Considered to be a stevia may do little stores as a dietary
Sweet Leaf America. Stevia dietary supplement harm, but FDA supplement.
rebaudianan leaves. and approved not as could not approve
extensive use of this

4.7.5 [Link]
Sweeteners with Consumer Controversial
Calories Source/Origin Product Uses
Trade Name Recommendations Issues
an additive, but as a sweetener due to
dietary supplement. concerns regarding
its effect on
reproduction, cancer
development, and
energy metabolism.

It is illegal to sell
true raw sugar in the
United States
because when raw it Over-consumption
contains dirt and has been linked to
Extracted from insect parts, as well several health Biscuits, cookies,
either sugar beets or as other byproducts. effects such as tooth cakes, pies, candy
Sucrose
~4 kcal/g sugar cane, which is Raw sugar products decay or dental canes, ice cream,
Sugar
then purified and sold in the United caries and sorbets, and as a
crystallized. States have actually contributes to food preservative.
gone through more increased risk for
than half of the chronic diseases.
same steps in the
refining process as
table sugar.

*Considered safe
for baking and
cooking.
Infants under twelve
months old should
Made from sucrose.
not be given honey
Contains nectar of
because their
flowering plants. Sweeteners in
digestive tracts
Made by bees. various foods and
cannot handle the
Sucrose is fructose beverages such as
Honey 3 kcal/g bacteria found in
+ glucose; however, sodas, teas,
honey. Older
honey contains alcoholic beverages,
children and adults
more calories than and baked goods.
are immune to these
sucrose because
effects. Honey
honey is denser.
contains some
harmful bacteria
that can cause fatal
food poisoning in
infants.

HFCS Dry form: 4 kcal/g; Corn is milled to Controversial Soft drinks, desserts,
high fructose Liquid form: 3 produce corn starch, because it is found candies, jellies.
corn syrup kcal/g then the corn starch ubiquitously in
is further processed processed food
to yield corn syrup. products, which
could lead to over-
consumption. Study
results are varied

4.7.6 [Link]
 Sweeteners with Consumer Controversial
Calories Source/Origin Product Uses
Trade Name Recommendations Issues
regarding its role in
chronic disease.

Provide bulk and

sweetness in the
Less likely to cause
Sugar Alcohols May cause diarrhea following sugar-free
Sugar alcohols. tooth decay than
Sorbital 2–4 kcal/g. and gastrointestinal items: cookies, jams,
Sorbitol is derived sucrose.
Xylitol Not calorie free distress if consumed jellies, chewing
from glucose. Sugar alcohols have
Mannitol in large amounts. gum, candies, mints,
a laxative effect.
pharmaceutical and
oral health products.

Regulation
Prior to introducing any new artificial sweetener into foods it is rigorously tested and must be legally approved by the FDA. The
FDA regulates artificial sweeteners along with other food additives, which number in the thousands. The FDA is responsible for
determining whether a food additive presents “a reasonable certainty of no harm” to consumers when used as proposed. The FDA
uses the best scientific evidence available to make the statement of no harm, but it does declare that science has its limits and that
the “FDA can never be absolutely certain of the absence of any risk from the use of any substance.”US Food and Drug
Administration. “Food Ingredients and Colors.” Accessed September 30, 2011. [Link]/food/foodingredie.../[Link].
The FDA additionally has established ADIs for artificial sweeteners. The ADIs are the maximum amount in milligrams per
kilogram of body weight considered safe to consume daily (mg/kg bw/day) and incorporates a large safety factor. The following list
contains the artificial sweeteners approved for use in foods and beverages in the United States, and their ADIs:
Acesulfame potassium (Sunett, Sweet One). ADI = 15 mg/kg bw/day
Aspartame (Equal, NutraSweet). ADI = 50 mg/kg bw/day
Neotame. ADI = 18 mg/kg bw/day
Saccharin (SugarTwin, Sweet’N Low). ADI = 5 mg/kg bw/day
Sucralose (Splenda). ADI = 5 mg/kg bw/day

Carbohydrates in a Kernel
Referring back to the wheat kernel mentioned at the opening of this chapter, recall that all components of the wheat kernel are
required in order to build an optimal healthy diet. The endosperm provides the carbohydrates, and the bran and germ contain the
majority of protein, vitamins, minerals, and fiber. Eating foods made with whole grains provides a better nutritional punch for your
health. Once whole grains are processed and refined, enrichment in only a few of these removed nutrients does not offset the gain
from consuming whole-grain products. Other dietary sources of carbohydrates that maximize nutrient uptake are vegetables, fruits,
beans, and low-fat dairy products. To avoid compromising your health, do not consume excessive amounts of carbohydrate foods
that contain added sugars, or that are high in sodium and saturated fat. Processed foods contain all of these ingredients in an
unwelcome nutrient package that negatively impacts health. Sugar substitutes provide one avenue of decreasing the intake of fast-
releasing carbohydrates, but there are others. Know that consumer demand for healthy carbohydrate choices is on the rise, so in the
future you can expect decreased prices, more variety of whole-grain products, and less added sugars.

The Bottom Line

Choose more slow-releasing carbohydrates, eat more fiber, and reduce consumption of foods high in added sugars.

Key Takeaways
In the food industry both fast-releasing and slow-releasing carbohydrates are utilized to give foods a wide spectrum of
functional attributes. The differences in chemical structure between the different carbohydrates confer their many different
functional uses in foods.

4.7.7 [Link]
 Due to the health consequences of consuming too many added sugars, sugar substitutes are widely used in many foods and
beverages.
Consuming foods and beverages containing sugar substitutes may benefit health by reducing the consumption of simple sugars,
which are higher in calories, cause tooth decay, and are potentially linked to chronic disease. However, the most common side
effect of consuming products containing sugar substitutes is gastrointestinal upset, a result of their incomplete digestion.
Prior to introducing any new artificial sweetener into foods it is rigorously tested and must be legally approved by the FDA.

Discussion Starters
1. Conduct a taste test of sugar and its substitutes. What do your taste buds tell you? Do you prefer foods with sugar substitutes or
the real thing?

4.7: The Food Industry- Functional Attributes of Carbohydrates and the Use of Sugar Substitutes is shared under a CC BY-NC-SA license and was
authored, remixed, and/or curated by LibreTexts.

4.7.8 [Link]
 CHAPTER OVERVIEW

5: Lipids
Learning Objectives
By the end of this chapter, you will be able to:
Describe the function and role of lipids in the body
Describe the process of lipid digestion and absorption
Describe tools and approaches for balancing your diet with lipids

5.1: Introduction to Lipids

5.2: The Functions of Lipids in the Body
5.3: The Role of Lipids in Food
5.4: How Lipids Work
5.5: Nonessential and Essential Fatty Acids
5.6: Digestion and Absorption of Lipids
5.7: Tools for Change
5.8: Lipids and the Food Industry
5.9: Lipids and Disease
5.10: Understanding Blood Cholesterol and Heart Attack Risk
5.11: A Personal Choice about Lipids
5.E: Lipids (Exercises)

This page titled 5: Lipids is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper, Marie
Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.

1
5.1: Introduction to Lipids
E hinu auaneʻi na nuku, he pōmaikaʻi ko laila
Where the mouths are shiny with fat food, prosperity is there

Figure : Image by Phu Thinh Co / CC BY-SA 2.0

The coconut is considered to be the ‘Tree of Life’ in the Pacific. The coconut provided wood for shelter and craftsmanship along
with being a source of hydration, animal feed and income through copra. It also serves many ecological functions such as a source
for shade, protection from the wind, and coastal erosion control.[1] A thriving coconut tree provided Pacific Island families with
great prosperity.
For many Pacific communities the coconut provided a valuable source of fat to a diet that was generally low in fat as the major
nutrient found in the mature coconut is fat. As you read further, you will learn the different types of fats, their essential roles in the
body, and the potential health consequences and benefits of diets rich in particular lipids. You will be better equipped to decide the
best way to get your nutritional punch from various fats in your diet.
Lipids are important molecules that serve different roles in the human body. A common misconception is that fat is simply
fattening. However, fat is probably the reason we are all here. Throughout history, there have been many instances when food was
scarce. Our ability to store excess caloric energy as fat for future usage allowed us to continue as a species during these times of
famine. So, normal fat reserves are a signal that metabolic processes are efficient and a person is healthy.
Lipids are a family of organic compounds that are mostly insoluble in water. Composed of fats and oils, lipids are molecules that
yield high energy and have a chemical composition mainly of carbon, hydrogen, and oxygen. Lipids perform three primary
biological functions within the body: they serve as structural components of cell membranes, function as energy storehouses, and
function as important signaling molecules.
The three main types of lipids are triglycerides, phospholipids, and sterols. Triglycerides make up more than 95 percent of lipids in
the diet and are commonly found in fried foods, vegetable oil, butter, whole milk, cheese, cream cheese, and some meats. Naturally
occurring triglycerides are found in many foods, including avocados, olives, corn, and nuts. We commonly call the triglycerides in
our food “fats” and “oils.” Fats are lipids that are solid at room temperature, whereas oils are liquid. As with most fats, triglycerides
do not dissolve in water. The terms fats, oils, and triglycerides are discretionary and can be used interchangeably. In this chapter
when we use the word fat, we are referring to triglycerides.
Phospholipids make up only about 2 percent of dietary lipids. They are water-soluble and are found in both plants and animals.
Phospholipids are crucial for building the protective barrier, or membrane, around your body’s cells. In fact, phospholipids are
synthesized in the body to form cell and organelle membranes. In blood and body fluids, phospholipids form structures in which fat
is enclosed and transported throughout the bloodstream.

5.1.1 [Link]
Sterols are the least common type of lipid. Cholesterol is perhaps the best well-known sterol. Though cholesterol has a notorious
reputation, the body gets only a small amount of its cholesterol through food—the body produces most of it. Cholesterol is an
important component of the cell membrane and is required for the synthesis of sex hormones, and bile salts.
Later in this chapter, we will examine each of these lipids in more detail and discover how their different structures function to
keep your body working.

Figure : Types of Lipids. Image by

Allison Calabrese / CC BY 4.0
1. Snowdon W, Osborn T. (2003). Coconut: It’s role in health. Secretariat of the Pacific. ↵

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5.1.2 [Link]
5.2: The Functions of Lipids in the Body
Storing Energy
The excess energy from the food we eat is digested and incorporated into adipose tissue, or fatty tissue. Most of the energy required
by the human body is provided by carbohydrates and lipids. As discussed in the Carbohydrates chapter, glucose is stored in the
body as glycogen. While glycogen provides a ready source of energy, lipids primarily function as an energy reserve. As you may
recall, glycogen is quite bulky with heavy water content, thus the body cannot store too much for long. Alternatively, fats are
packed together tightly without water and store far greater amounts of energy in a reduced space. A fat gram is densely
concentrated with energy—it contains more than double the amount of energy than a gram of carbohydrate. Energy is needed to
power the muscles for all the physical work and play an average person or child engages in. For instance, the stored energy in
muscles propels an athlete down the track, spurs a dancer’s legs to showcase the latest fancy steps, and keeps all the moving parts
of the body functioning smoothly.
Unlike other body cells that can store fat in limited supplies, fat cells are specialized for fat storage and are able to expand almost
indefinitely in size. An overabundance of adipose tissue can result in undue stress on the body and can be detrimental to your
health. A serious impact of excess fat is the accumulation of too much cholesterol in the arterial wall, which can thicken the walls
of arteries and lead to cardiovascular disease. Thus, while some body fat is critical to our survival and good health, in large
quantities it can be a deterrent to maintaining good health.

Regulating and Signaling

Triglycerides control the body’s internal climate, maintaining constant temperature. Those who don’t have enough fat in their
bodies tend to feel cold sooner, are often fatigued, and have pressure sores on their skin from fatty acid deficiency. Triglycerides
also help the body produce and regulate hormones. For example, adipose tissue secretes the hormone leptin, which regulates
appetite. In the reproductive system, fatty acids are required for proper reproductive health. Women who lack proper amounts may
stop menstruating and become infertile. Omega-3 and omega-6 essential fatty acids help regulate cholesterol and blood clotting and
control inflammation in the joints, tissues, and bloodstream. Fats also play important functional roles in sustaining nerve impulse
transmission, memory storage, and tissue structure. More specifically in the brain, lipids are focal to brain activity in structure and
in function. They help form nerve cell membranes, insulate neurons, and facilitate the signaling of electrical impulses throughout
the brain.

Insulating and Protecting

Did you know that up to 30 percent of body weight is comprised of fat tissue? Some of this is made up of visceral fat or adipose
tissue surrounding delicate organs. Vital organs such as the heart, kidneys, and liver are protected by visceral fat. The composition
of the brain is outstandingly 60 percent fat, demonstrating the major structural role that fat serves within the body. You may be
most familiar with subcutaneous fat, or fat underneath the skin. This blanket layer of tissue insulates the body from extreme
temperatures and helps keep the internal climate under control. It pads our hands and buttocks and prevents friction, as these areas
frequently come in contact with hard surfaces. It also gives the body the extra padding required when engaging in physically
demanding activities such as ice- or roller skating, horseback riding, or snowboarding.

Aiding Digestion and Increasing Bioavailability

The dietary fats in the foods we eat break down in our digestive systems and begin the transport of precious micronutrients. By
carrying fat-soluble nutrients through the digestive process, intestinal absorption is improved. This improved absorption is also
known as increased bioavailability. Fat-soluble nutrients are especially important for good health and exhibit a variety of functions.
Vitamins A, D, E, and K—the fat-soluble vitamins—are mainly found in foods containing fat (Figure ). Some fat-soluble
vitamins (such as vitamin A) are also found in naturally fat-free foods such as green leafy vegetables, carrots, and broccoli. These
vitamins are best absorbed when combined with foods containing fat. Fats also increase the bioavailability of compounds known as
phytochemicals, which are plant constituents such as lycopene (found in tomatoes) and beta-carotene (found in carrots).
Phytochemicals are believed to promote health and well-being. As a result, eating tomatoes with olive oil or salad dressing will

5.2.1 [Link]
facilitate lycopene absorption. Other essential nutrients, such as essential fatty acids, are constituents of the fats themselves and
serve as building blocks of a cell.

Figure : Food Sources of Omega 3’s. n/a

Note that removing the lipid elements from food also takes away the food’s fat-soluble vitamin content. When products such as
grain and dairy are processed, these essential nutrients are lost. Manufacturers replace these nutrients through a process called
enrichment.

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5.2.2 [Link]
5.3: The Role of Lipids in Food
High Energy Source
Fat-rich foods naturally have a high caloric density. Foods that are high in fat contain more calories than foods high in protein or
carbohydrates. As a result, high-fat foods are a convenient source of energy. For example, 1 gram of fat or oil provides 9
kilocalories of energy, compared with 4 kilocalories found in 1 gram of carbohydrate or protein. Depending on the level of physical
activity and on nutritional needs, fat requirements vary greatly from person to person. When energy needs are high, the body
welcomes the high-caloric density of fats. For instance, infants and growing children require proper amounts of fat to support
normal growth and development. If an infant or child is given a low-fat diet for an extended period, growth and development will
not progress normally. Other individuals with high-energy needs are athletes, people who have physically demanding jobs, and
those recuperating from illness.
When the body has used all of its calories from carbohydrates (this can occur after just twenty minutes of exercise), it initiates fat
usage. A professional swimmer must consume large amounts of food energy to meet the demands of swimming long distances, so
eating fat-rich foods makes sense. In contrast, if a person who leads a sedentary lifestyle eats the same high-density fat foods, they
will intake more fat calories than their body requires within just a few bites. Use caution—consumption of calories over and
beyond energy requirements is a contributing factor to obesity.

Smell and Taste

Fat contains dissolved compounds that contribute to mouth-watering aromas and flavors. Fat also adds texture to food. Baked foods
are supple and moist. Frying foods locks in flavor and lessens cooking time. How long does it take you to recall the smell of your
favorite food cooking? What would a meal be without that savory aroma to delight your senses and heighten your preparedness for
eating a meal?
Fat plays another valuable role in nutrition. Fat contributes to satiety, or the sensation of fullness. When fatty foods are swallowed
the body responds by enabling the processes controlling digestion to retard the movement of food along the digestive tract, thus
promoting an overall sense of fullness. Oftentimes before the feeling of fullness arrives, people overindulge in fat-rich foods,
finding the delectable taste irresistible. Indeed, the very things that make fat-rich foods attractive also make them a hindrance to
maintaining a healthful diet.

 Tools for Change

It is important to strike a proper balance between omega-3 and omega-6 fats in your diet. Research suggests that a diet that is
too high in omega-6 fats distorts the balance of proinflammatory agents, promoting chronic inflammation and causing the
potential for health problems such as asthma, arthritis, allergies, or diabetes. Omega-6 fats compete with omega-3 fats for
enzymes and will actually replace omega-3 fats. The typical western diet is characterized by an excessive consumption of
foods high in omega-6 fatty acids. To gain proper balance between the two, increase your omega-3 fat intake by eating more
fatty fish or other sources of omega-3 fatty acids at least two times per week.

Figure : There are many sources of omega-3 foods.

An interactive or media element has been excluded from this version of the text. You can view it online here:
[Link]/humannutrition2/?p=206

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5.3.2 [Link]
5.4: How Lipids Work
Lipids are unique organic compounds, each serving key roles and performing specific functions within the body. As we discuss the
various types of lipids (triglycerides, phospholipids, and sterols) in further detail, we will compare their structures and functions
and examine their impact on human health.

Triglycerides Structure and Functions

Triglycerides are the main form of lipid found in the body and in the diet. Fatty acids and glycerol are the building blocks of
triglycerides (Figure ). Glycerol is a thick, smooth, syrupy compound that is often used in the food industry. To form a
triglyceride, a glycerol molecule is joined by three fatty acid chains. triglycerides contain varying mixtures of fatty acids.

Figure : The Structure of a Triglycerides. Image by

Allison Calabrese/ CC BY 4.0

Fatty Acids
Fatty acids determine if the compound is solid or liquid at room temperature. Fatty acids consist of a carboxylic acid ( )
group on one end of a carbon chain and a methyl group ( ) on the other end. Fatty acids can differ from one another in two
important ways—carbon chain length and degree of saturation.

It’s All in the Chain

Fatty acids have different chain lengths and different compositions. Foods have fatty acids with chain lengths between four and
twenty-four carbons and most of them contain an even number of carbon atoms. When the carbon chain length is shorter, the
melting point of the fatty acid becomes lower—and the fatty acid becomes more liquid.

5.4.1 [Link]
Figure : Structures of a Saturated, Monounsaturated, and Polyunsaturated Fat. Image by Allison Calabrese / CC BY 4.0

 Fatty Acid Types in the Body

The fatty-acid profile of the diet directly correlates to the tissue lipid profile of the body. It may not solely be the quantity of
dietary fat that matters. More directly, the type of dietary fat ingested has been shown to affect body weight, composition, and
metabolism. The fatty acids consumed are often incorporated into the triglycerides within the body. Evidence confirms that
saturated fatty acids are linked to higher rates of weight retention when compared to other types of fatty acids. Alternatively,
the fatty acids found in fish oil are proven to reduce the rate of weight gain as compared to other fatty acids.[1]

Degrees of Saturation
Fatty acid chains are held together by carbon atoms that attach to each other and to hydrogen atoms. The term saturation refers to
whether or not a fatty acid chain is filled (or “saturated”) to capacity with hydrogen atoms. If each available carbon bond holds a
hydrogen atom we call this a saturated fatty acid chain. All carbon atoms in such a fatty acid chain are bonded with single bonds.
Sometimes the chain has a place where hydrogen atoms are missing. This is referred to as the point of unsaturation.
When one or more bonds between carbon atoms are a double bond (C=C), that fatty acid is called an unsaturated fatty acid, as it
has one or more points of unsaturation. Any fatty acid that has only one double bond is a monounsaturated fatty acid, an example of
which is olive oil (75 percent of its fat is monounsaturated). Monounsaturated fats help regulate blood cholesterol levels, thereby
reducing the risk for heart disease and stroke. A polyunsaturated fatty acid is a fatty acid with two or more double bonds or two or
more points of unsaturation. Soybean oil contains high amounts of polyunsaturated fatty acids. Both monounsaturated fats and
polyunsaturated fats provide nutrition that is essential for normal cell development and healthy skin.

5.4.2 [Link]
Foods that have a high percentage of saturated fatty acids tend to be solid at room temperature. Examples of these are fats found in
chocolate (stearic acid, an eighteen-carbon saturated fatty acid is a primary component) and meat. Foods rich in unsaturated fatty
acids, such as olive oil (oleic acid, an eighteen-carbon unsaturated fatty acid, is a major component) tend to be liquid at room
temperature. Flaxseed oil is rich in alpha-linolenic acid, which is an unsaturated fatty acid and becomes a thin liquid at room
temperature.
Knowing the connection between chain length, degree of saturation, and the state of the fatty acid (solid or liquid) is important for
making food choices. If you decide to limit or redirect your intake of fat products, then choosing unsaturated fat is more beneficial
than choosing a saturated fat. This choice is easy enough to make because unsaturated fats tend to be liquid at room temperature
(for example, olive oil) whereas saturated fats tend to be solid at room temperature (for example, butter). Avocados are rich in
unsaturated fats. Most vegetable and fish oils contain high quantities of polyunsaturated fats. Olive oil and canola oil are also rich
in monounsaturated fats. Conversely, tropical oils are an exception to this rule in that they are liquid at room temperature yet high
in saturated fat. Palm oil (often used in food processing) is highly saturated and has been proven to raise blood cholesterol.
Shortening, margarine, and commercially prepared products (in general) report to use only vegetable-derived fats in their
processing. But even so, much of the fat they use may be in the saturated and trans fat categories.

Cis or Trans Fatty Acids?

The introduction of a carbon double bond in a carbon chain, as in an unsaturated fatty acid, can result in different structures for the
same fatty acid composition. When the hydrogen atoms are bonded to the same side of the carbon chain, it is called a cis fatty acid.
Because the hydrogen atoms are on the same side, the carbon chain has a bent structure. Naturally occurring fatty acids usually
have a cis configuration (Figure ).
In a trans fatty acid, the hydrogen atoms are attached on opposite sides of the carbon chain. Unlike cis fatty acids, most trans fatty
acids are not found naturally in foods, but are a result of a process called hydrogenation. Hydrogenation is the process of adding
hydrogen to the carbon double bonds, thus making the fatty acid saturated (or less unsaturated, in the case of partial
hydrogenation). This is how vegetable oils are converted into semisolid fats for use in the manufacturing process.
According to the ongoing Harvard Nurses’ Health Study, trans fatty acids have been associated with increased risk for coronary
heart disease because of the way they negatively impact blood cholesterol levels.[2]

Figure : Structures of Saturated, Unsaturated, Cis and Trans fatty

Acids. Image by Openstax Biology / CC BY 4.0
Interestingly, some naturally occurring trans fats do not pose the same health risks as their artificially engineered counterparts.
These trans fats are found in ruminant animals such as cows, sheep, and goats, resulting in trans fatty acids being present in our
meat, milk, and other dairy product supply. Reports from the US Department of Agriculture (USDA) indicate that these trans fats

5.4.3 [Link]
comprise 15 to 20 percent of the total trans-fat intake in our diet. While we know that trans fats are not exactly harmless, it seems
that any negative effect naturally occurring trans fats have are counteracted by the presence of other fatty acid molecules in these
animal products, which work to promote human health.
1. Mori T, Kondo H. (2007). Dietary fish oil upregulates intestinal lipid metabolism and reduces body weight gain in C57BL/6J
mice. Journal of Nutrition, 137(12):2629-34. [Link] Accessed September 22, 2017.
↵
2. Introduction to “Fats and Cholesterol: Out with the Bad, In with the Good” The Nutrition Source. Harvard School of Public
Health. [Link] Updated 2017. Accessed
September 28, 2017. ↵

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5.4.4 [Link]
5.5: Nonessential and Essential Fatty Acids
Fatty acids are vital for the normal operation of all body systems. The circulatory system, respiratory system, integumentary
system, immune system, brain, and other organs require fatty acids for proper function. The body is capable of synthesizing most of
the fatty acids it needs from food. These fatty acids are known as nonessential fatty acids. However, there are some fatty acids that
the body cannot synthesize and these are called essential fatty acids. It is important to note that nonessential fatty acids doesn’t
mean unimportant; the classification is based solely on the ability of the body to synthesize the fatty acid.
Essential fatty acids must be obtained from food. They fall into two categories—omega-3 and omega-6. The 3 and 6 refer to the
position of the first carbon double bond and the omega refers to the methyl end of the chain. Omega-3 and omega-6 fatty acids are
precursors to important compounds called eicosanoids. Eicosanoids are powerful hormones that control many other hormones and
important body functions, such as the central nervous system and the immune system. Eicosanoids derived from omega-6 fatty
acids are known to increase blood pressure, immune response, and inflammation. In contrast, eicosanoids derived from omega-3
fatty acids are known to have heart-healthy effects. Given the contrasting effects of the omega-3 and omega-6 fatty acids, a proper
dietary balance between the two must be achieved to ensure optimal health benefits.
Essential fatty acids play an important role in the life and death of cardiac cells, immune system function, and blood pressure
regulation. Docosahexaenoic acid (DHA) is an omega-3 essential fatty acid shown to play important roles in synaptic transmission
in the brain during fetal development.
Some excellent sources of omega-3 and omega-6 essential fatty acids are fish, flaxseed oil, hemp, walnuts, and leafy vegetables.
Because these essential fatty acids are easily accessible, essential fatty acid deficiency is extremely rare.

Figure : Essential Fatty Acids. Image

by Allison Calabrese / CC BY 4.0

Phospholipids
Like triglycerides, phospholipids have a glycerol backbone. But unlike triglycerides, phospholipids are diglycerides (two fatty-acid
molecules attached to the glycerol backbone) while their third fatty-acid chain has a phosphate group coupled with a nitrogen-
containing group. This unique structure makes phospholipids water soluble. Phospholipids are what we call amphiphilic—the fatty-
acid sides are hydrophobic (dislike water) and the phosphate group is hydrophilic (likes water).
In the body phospholipids bind together to form cell membranes. The amphiphilic nature of phospholipids governs their function as
components of cell membranes. The phospholipids form a double layer in cell membranes, thus effectively protecting the inside of
the cell from the outside environment while at the same time allowing for transport of fat and water through the membrane.

5.5.1 [Link]
 Figure : The Structure of a Phospholipid. Image by
Allison Calabrese / CC BY 4.0
Phospholipids are ideal emulsifiers that can keep oil and water mixed. Emulsions are mixtures of two liquids that do not mix.
Without emulsifiers, the fat and water content would be somewhat separate within food. Lecithin (phosphatidylcholine), found in
egg yolk, honey, and mustard, is a popular food emulsifier. Mayonnaise demonstrates lecithin’s ability to blend vinegar and oil to
create the stable, spreadable condiment that so many enjoy. Food emulsifiers play an important role in making the appearance of
food appetizing. Adding emulsifiers to sauces and creams not only enhances their appearance but also increases their freshness.
Lecithin’s crucial role within the body is clear, because it is present in every cell throughout the body; 28 percent of brain matter is
composed of lecithin and 66 percent of the fat in the liver is lecithin. Many people attribute health-promoting properties to lecithin,
such as its ability to lower blood cholesterol and aid with weight loss. There are several lecithin supplements on the market
broadcasting these claims. However, as the body can make most phospholipids, it is not necessary to consume them in a pill. The
body makes all of the lecithin that it needs.

Figure : The Difference Between

Triglycerides and Phospholipids. Image by Allison Calabrese / CC BY 4.0

Sterols
Sterols have a very different structure from triglycerides and phospholipids. Most sterols do not contain any fatty acids but rather
multiring structures. They are complex molecules that contain interlinking rings of carbon atoms, with side chains of carbon,

5.5.2 [Link]
hydrogen, and oxygen attached. Cholesterol is the best-known sterol because of its role in heart disease. It forms a large part of the
plaque that narrows the arteries in atherosclerosis. In stark contrast, cholesterol does have specific beneficial functions to perform
in the body. Like phospholipids, cholesterol is present in all body cells as it is an important substance in cell membrane structure.
Approximately 25 percent of cholesterol in the body is localized in brain tissue. Cholesterol is used in the body to make a number
of important things, including vitamin D, glucocorticoids, and the sex hormones, progesterone, testosterone, and estrogens.
Notably, the sterols found in plants resemble cholesterol in structure. However, plant sterols inhibit cholesterol absorption in the
human body, which can contribute to lower cholesterol levels.
Although cholesterol is preceded by its infamous reputation, it is clearly a vital substance in the body that poses a concern only
when there is excess accumulation of it in the blood. Like lecithin, the body can synthesize cholesterol.

Figure : The Structure of Cholesterol. “Cholesterol Chemical Structure” by

Wesalius / Public Domain

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5.5.3 [Link]
5.6: Digestion and Absorption of Lipids
Lipids are large molecules and generally are not water-soluble. Like carbohydrates and protein, lipids are broken into small
components for absorption. Since most of our digestive enzymes are water-based, how does the body break down fat and make it
available for the various functions it must perform in the human body?

From the Mouth to the Stomach

The first step in the digestion of triglycerides and phospholipids begins in the mouth as lipids encounter saliva. Next, the physical
action of chewing coupled with the action of emulsifiers enables the digestive enzymes to do their tasks. The enzyme lingual lipase,
along with a small amount of phospholipid as an emulsifier, initiates the process of digestion. These actions cause the fats to
become more accessible to the digestive enzymes. As a result, the fats become tiny droplets and separate from the watery
components.

Figure : Lipid Digestion and

Absorption. Image by Allison Calabrese / CC BY 4.0
In the stomach, gastric lipase starts to break down triglycerides into diglycerides and fatty acids. Within two to four hours after
eating a meal, roughly 30 percent of the triglycerides are converted to diglycerides and fatty acids. The stomach’s churning and
contractions help to disperse the fat molecules, while the diglycerides derived in this process act as further emulsifiers. However,
even amid all of this activity, very little fat digestion occurs in the stomach.

Going to the Bloodstream

As stomach contents enter the small intestine, the digestive system sets out to manage a small hurdle, namely, to combine the
separated fats with its own watery fluids. The solution to this hurdle is bile. Bile contains bile salts, lecithin, and substances derived
from cholesterol so it acts as an emulsifier. It attracts and holds onto fat while it is simultaneously attracted to and held on to by

5.6.1 [Link]
water. Emulsification increases the surface area of lipids over a thousand-fold, making them more accessible to the digestive
enzymes.
Once the stomach contents have been emulsified, fat-breaking enzymes work on the triglycerides and diglycerides to sever fatty
acids from their glycerol foundations. As pancreatic lipase enters the small intestine, it breaks down the fats into free fatty acids and
monoglycerides. Yet again, another hurdle presents itself. How will the fats pass through the watery layer of mucus that coats the
absorptive lining of the digestive tract? As before, the answer is bile. Bile salts envelop the fatty acids and monoglycerides to form
micelles. Micelles have a fatty acid core with a water-soluble exterior. This allows efficient transportation to the intestinal
microvillus. Here, the fat components are released and disseminated into the cells of the digestive tract lining.

Figure : Micelle Formation. Scheme of a micelle formed by

phospholipids in an aqueous solution by Emmanuel Boutet / CC BY-SA 3.0

Figure : Schematic Diagram Of A Chylomicron.

Chylomicrons Contain Triglycerides Cholesterol Molecules and other Lipids by OpenStax College / CC BY 3.0
Just as lipids require special handling in the digestive tract to move within a water-based environment, they require similar
handling to travel in the bloodstream. Inside the intestinal cells, the monoglycerides and fatty acids reassemble themselves into
triglycerides. Triglycerides, cholesterol, and phospholipids form lipoproteins when joined with a protein carrier. Lipoproteins have
an inner core that is primarily made up of triglycerides and cholesterol esters (a cholesterol ester is a cholesterol linked to a fatty
acid). The outer envelope is made of phospholipids interspersed with proteins and cholesterol. Together they form a chylomicron,
which is a large lipoprotein that now enters the lymphatic system and will soon be released into the bloodstream via the jugular
vein in the neck. Chylomicrons transport food fats perfectly through the body’s water-based environment to specific destinations
such as the liver and other body tissues.
Cholesterols are poorly absorbed when compared to phospholipids and triglycerides. Cholesterol absorption is aided by an increase
in dietary fat components and is hindered by high fiber content. This is the reason that a high intake of fiber is recommended to

5.6.2 [Link]
decrease blood cholesterol. Foods high in fiber such as fresh fruits, vegetables, and oats can bind bile salts and cholesterol,
preventing their absorption and carrying them out of the colon.
If fats are not absorbed properly as is seen in some medical conditions, a person’s stool will contain high amounts of fat. If fat
malabsorption persists the condition is known as steatorrhea. Steatorrhea can result from diseases that affect absorption, such as
Crohn’s disease and cystic fibrosis.

Figure : Cholesterol and Soluble Fiber. Image by

Allison Calabrese / CC BY 4.0

The Truth about Storing and Using Body Fat

Before the prepackaged food industry, fitness centers, and weight-loss programs, our ancestors worked hard to even locate a meal.
They made plans, not for losing those last ten pounds to fit into a bathing suit for vacation, but rather for finding food. Today, this is
why we can go long periods without eating, whether we are sick with a vanished appetite, our physical activity level has increased,
or there is simply no food available. Our bodies reserve fuel for a rainy day.
One way the body stores fat was previously touched upon in the Carbohydrates chapter. The body transforms carbohydrates into
glycogen that is in turn stored in the muscles for energy. When the muscles reach their capacity for glycogen storage, the excess is
returned to the liver, where it is converted into triglycerides and then stored as fat.
In a similar manner, much of the triglycerides the body receives from food is transported to fat storehouses within the body if not
used for producing energy. The chylomicrons are responsible for shuttling the triglycerides to various locations such as the
muscles, breasts, external layers under the skin, and internal fat layers of the abdomen, thighs, and buttocks where they are stored
by the body in adipose tissue for future use. How is this accomplished? Recall that chylomicrons are large lipoproteins that contain
a triglyceride and fatty-acid core. Capillary walls contain an enzyme called lipoprotein-lipase that dismantles the triglycerides in
the lipoproteins into fatty acids and glycerol, thus enabling these to enter into the adipose cells. Once inside the adipose cells, the
fatty acids and glycerol are reassembled into triglycerides and stored for later use. Muscle cells may also take up the fatty acids and
use them for muscular work and generating energy. When a person’s energy requirements exceed the amount of available fuel
presented from a recent meal or extended physical activity has exhausted glycogen energy reserves, fat reserves are retrieved for
energy utilization.
As the body calls for additional energy, the adipose tissue responds by dismantling its triglycerides and dispensing glycerol and
fatty acids directly into the blood. Upon receipt of these substances the energy-hungry cells break them down further into tiny
fragments. These fragments go through a series of chemical reactions that yield energy, carbon dioxide, and water.

5.6.3 [Link]
 Figure : Storing and Using Fat. Image by
Allison Calabrese / CC BY 4.0

Understanding Blood Cholesterol

You may have heard of the abbreviations LDL and HDL with respect to heart health. These abbreviations refer to low-density
lipoprotein (LDL) and high-density lipoprotein (HDL), respectively. Lipoproteins are characterized by size, density, and
composition. As the size of the lipoprotein increases, the density decreases. This means that HDL is smaller than LDL. Why are
they referred to as “good” and “bad” cholesterol? What should you know about these lipoproteins?

Major Lipoproteins
Recall that chylomicrons are transporters of fats throughout the watery environment within the body. After about ten hours of
circulating throughout the body, chylomicrons gradually release their triglycerides until all that is left of their composition is
cholesterol-rich remnants. These remnants are used as raw materials by the liver to formulate specific lipoproteins. Following is a
list of the various lipoproteins and their functions:
VLDLs. Very low-density lipoproteins are made in the liver from remnants of chylomicrons and transport triglycerides from the
liver to various tissues in the body. As the VLDLs travel through the circulatory system, the lipoprotein lipase strips the VLDL
of triglycerides. As triglyceride removal persists, the VLDLs become intermediate-density lipoproteins.
IDLs. Intermediate-density lipoproteins transport a variety of fats and cholesterol in the bloodstream and are a little under half
triglyceride in composition. While travelling in the bloodstream, cholesterol is gained from other lipoproteins while circulating
enzymes strip its phospholipid component. When IDLs return to the liver, they are transformed into low-density lipoprotein.
LDLs. As low-density lipoproteins are commonly known as the “bad cholesterol” it is imperative that we understand their
function in the body so as to make healthy dietary and lifestyle choices. LDLs carry cholesterol and other lipids from the liver
to tissue throughout the body. LDLs are comprised of very small amounts of triglycerides, and house over 50 percent
cholesterol and cholesterol esters. How does the body receive the lipids contained therein? As the LDLs deliver cholesterol and
other lipids to the cells, each cell’s surface has receptor systems specifically designed to bind with LDLs. Circulating LDLs in
the bloodstream bind to these LDL receptors and are consumed. Once inside the cell, the LDL is taken apart and its cholesterol
is released. In liver cells these receptor systems aid in controlling blood cholesterol levels as they bind the LDLs. A deficiency
of these LDL binding mechanisms will leave a high quantity of cholesterol traveling in the bloodstream, which can lead to heart
disease or atherosclerosis. Diets rich in saturated fats will prohibit the LDL receptors which, are critical for regulating
cholesterol levels.

5.6.4 [Link]
 HDLs. High-density lipoproteins are responsible for carrying cholesterol out of the bloodstream and into the liver, where it is
either reused or removed from the body with bile. HDLs have a very large protein composition coupled with low cholesterol
content (20 to 30 percent) compared to the other lipoproteins. Hence, these high-density lipoproteins are commonly called
“good cholesterol.”

Figure : Lipoprotein Classes.

[Link]
The classification of the major types of lipoproteins are based on their densities. Density range is shown as well as lipid (red) and
protein (blue) content. (Diagram not to scale) / CC BY 3.0

Blood Cholesterol Recommendations

For healthy total blood cholesterol, the desired range you would want to maintain is under 200 mg/dL. More specifically, when
looking at individual lipid profiles, a low amount of LDL and a high amount of HDL prevents excess buildup of cholesterol in the
arteries and wards off potential health hazards. An LDL level of less than 100 milligrams per deciliter is ideal while an LDL level
above 160 mg/dL would be considered high. In contrast, a low value of HDL is a telltale sign that a person is living with major
risks for disease. Values of less than 40 mg/dL for men and 50 mg/dL for women mark a risk factor for developing heart disease. In
short, elevated LDL blood lipid profiles indicate an increased risk of heart attack, while elevated HDL blood lipid profiles indicate
a reduced [Link] University of Maryland Medical Center reports that omega-3 fatty acids promote lower total cholesterol and
lower triglycerides in people with high cholesterol.[1]
It is suggested that people consume omega-3 fatty acids such as alpha-linolenic acid in their diets regularly. Polyunsaturated fatty
acids are especially beneficial to consume because they both lower LDL and elevate HDL, thus contributing to healthy blood
cholesterol levels. The study also reveals that saturated and trans fatty acids serve as catalysts for the increase of LDL cholesterol.
Additionally, trans fatty acids decrease HDL levels, which can impact negatively on total blood cholesterol.
1. Omega-3 fatty acids. University of Maryland Medical Center. [Link]
Updated August 5, 2015. Accessed September 28, 2017. ↵

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5.6.5 [Link]
5.7: Tools for Change
Being conscious of the need to reduce cholesterol means limiting the consumption of saturated fats and trans fats. Remember that
saturated fats found in some meat, whole-fat dairy products, and tropical oils elevate your total cholesterol. Trans fats, such as the
ones often found in margarines, processed cookies, pastries, crackers, fried foods, and snack foods also elevate your cholesterol
levels. Read and select from the following suggestions as you plan ahead:
1. Soluble fiber reduces cholesterol absorption in the bloodstream. Try eating more oatmeal, oat bran, kidney beans, apples, pears,
citrus fruits, barley, and prunes.
2. Fatty fish are heart-healthy due to high levels of omega-3 fatty acids that reduce inflammation and lower cholesterol levels.
Consume mackerel, lake trout, herring, sardines, tuna, salmon, and halibut. Grilling or baking is the best to avoid unhealthy
trans fats that could be added from frying oil.
3. Walnuts, almonds, peanuts, hazelnuts, pecans, some pine nuts, and pistachios all contain high levels of unsaturated fatty acids
that aid in lowering LDL. Make sure the nuts are raw and unsalted. Avoid sugary or salty nuts. One ounce each day is a good
amount.
4. Olive oil contains a strong mix of antioxidants and monounsaturated fat, and may lower LDL while leaving HDL intact. Two
tablespoons per day in place of less healthy saturated fats may contribute to these heart-healthy effects without adding extra
calories. Extra virgin olive oil promises a greater effect, as the oil is minimally processed and contains more heart-healthy
antioxidants.

Testing Your Lipid Profile

The danger of consuming foods rich in cholesterol and saturated and trans fats cannot be overemphasized. Regular testing can
provide the foreknowledge necessary to take action to help prevent any life-threatening events.
Current guidelines recommend testing for anyone over age twenty. If there is family history of high cholesterol, your healthcare
provider may suggest a test sooner than this. Testing calls for a blood sample to be drawn after nine to twelve hours of fasting for
an accurate reading. (By this time, most of the fats ingested from the previous meal have circulated through the body and the
concentration of lipoproteins in the blood will be stabilized.)
According to the National Institutes of Health (NIH), the following total cholesterol values are used to target treatment[1]
Desirable. Under 200 mg/dL
Borderline high. 200–239 mg/dL
High risk. 240 mg/dL and up
According to the NIH, the following desired values are used to measure an overall lipid profile:
LDL. Less than 160 mg/dL (if you have heart disease or diabetes, less than 100 mg/dL)
HDL. Greater than 40–60 mg/dL
triglycerides. 10–150 mg/dL
VLDL. 2–38 mg/dL

Balancing Your Diet with Lipids

You may reason that if some fats are healthier than other fats, why not consume as much healthy fat as desired? Remember,
everything in moderation. As we review the established guidelines for daily fat intake, the importance of balancing fat consumption
with proper fat sources will be explained.

Recommended Fat Intake

The acceptable macronutrient distribution range (AMDR) from the Dietary Reference Intake Committee for adult fat consumption
is as follows[2]:
Fat calories should be limited to 20–35 percent of total calories with most fats coming from polyunsaturated and
monounsaturated fats, such as those found in fish, nuts, and vegetable oils.

5.7.1 [Link]
 Consume fewer than 10 percent of calories from saturated fats. Some studies suggest that lowering the saturated fat content to
less than 7 percent can further reduce the risk of heart disease.
Keep the consumption of trans fats (any food label that reads hydrogenated or partially hydrogenated oil) to a minimum, less
than 1 percent of calories.
Think lean and low-fat when selecting meat, poultry, milk, and milk products.
The current AMDR for child and adolescent fat consumption (for children over four) are as follows:
For children between ages four and eighteen years, between 25 and 35 percent of caloric intake should be from fat.
For all age groups, most fats should come from polyunsaturated and monounsaturated fats such as fish, nuts, and vegetable oils.

Identifying Sources of Fat

Population-based studies of American diets have shown that intake of saturated fat is more excessive than intake of trans fat and
cholesterol. Saturated fat is a prominent source of fat for most people as it is so easily found in animal fats, tropical oils such as
coconut and palm oil, and full-fat dairy products. Oftentimes the fat in the diet of an average young person comes from foods such
as cheese, pizza, cookies, chips, desserts, and animal meats such as chicken, burgers, sausages, and hot dogs. To aim for healthier
dietary choices, the American Heart Association (AHA) recommends choosing lean meats and vegetable alternatives, choosing
dairy products with low fat content, and minimizing the intake of trans fats. The AHA guidelines also recommend consuming fish,
especially oily fish, at least twice per week.[3]
These more appropriate dietary choices will allow for enjoyment of a wide variety of foods while providing the body with the
recommended levels of fat from healthier sources. Evaluate the following sources of fat in your overall dietary pattern:
Monounsaturated fat. This type of fat is found in plant oils. Common sources are nuts (almonds, cashews, pecans, peanuts, and
walnuts) and nut products, avocados, olive oil, sesame oil, high oleic safflower oil, sunflower oil, and canola oil.
Polyunsaturated fat. This type of fat is found mainly in plant-based foods, oils, and fish. Common sources are nuts (walnuts,
hazel nuts, pecans, almonds, and peanuts), soybean oil, corn oil, safflower oil, flaxseed oil, canola oil, and fish (trout, herring,
and salmon).
Saturated fat. This fat is found in animal products, dairy products, palm and coconut oils, and cocoa butter. Limit these products
to less than 10 percent of your overall dietary fat consumption.
Trans fatty acids. Stick margarines, shortening, fast foods, commercial baked goods, and some snack foods contain trans fats.
Limit your consumption of these products to keep trans fats to less than 1 percent of your fat consumption.
Omega-3 fatty acids (linolenic acid). Good sources of these are canola oil, flaxseed oil, soybean oil, olive oil, nuts, seeds, whole
grains, legumes, and green leafy vegetables.
Omega-3 fatty acids (DHA and EPA). Good sources of these are cod liver oil and fish such as tuna, herring, mackerel, salmon,
and trout.
Omega-6 fatty acids (linoleic acid). Eggs, poultry, most vegetable oils, wheat germ oil, whole grains, baked goods, and cereals
contain these fatty acids. Omega-6 fatty acids are present abundantly in nuts and seeds such as flaxseeds, sunflower seeds,
sesame seeds, and watermelon seeds.

Omega-3 and Omega-6 Fatty Acids

Recall that the body requires fatty acids and is adept at synthesizing the majority of these from fat, protein, and carbohydrate.
However, when we say essential fatty acid we are referring to the two fatty acids that the body cannot create on its own, namely,
linolenic acid and linoleic acid.
Omega-3 Fatty Acids. At the helm of the omega-3 fatty acid family is linolenic acid. From this fatty acid, the body can make
eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Linolenic acid is found in nuts, seeds, whole grains, legumes,
and vegetable oil such as soybean, canola, and flaxseed. EPA and DHA are found abundantly in fatty fish.
Omega-6 Fatty Acids. At the helm of the omega-6 fatty acid family is linoleic acid. Like linolenic acid, the body uses linoleic
acid to make other important substances such as arachidonic acid (ARA) that is used to make eicosanoids. Recall that
eicosanoids perform critical roles in the body as they affect a broad spectrum of functions. The word eicosanoid originates from
the Greek word eicosa, meaning twenty, because this hormone is derived from ARA that is twenty carbon atoms in length.
Eicosanoids affect the synthesis of all other body hormones and control all body systems, such as the central nervous system

5.7.2 [Link]
 and the immune system. Among the many functions eicosanoids serve in the body, their primary function is to regulate
inflammation. Without these hormones the body would not be able to heal wounds, fight infections, or fight off illness each
time a foreign germ presented itself. Eicosanoids work together with the body’s immune and inflammatory processes to play a
major role in several important body functions, such as circulation, respiration, and muscle movement.

Attain the Omega-3 and Omega-6 Balance

As our food choices evolve, the sources of omega-6 fatty acids in our diets are increasing at a much faster rate than sources of
omega-3 fatty acids. Omega-3s are plentiful in diets of non-processed foods where grazing animals and foraging chickens roam
free, eating grass, clover, alfalfa, and grass-dwelling insects. In contrast, today’s western diets are bombarded with sources of
omega-6. For example, we have oils derived from seeds and nuts and from the meat of animals that are fed grain. Vegetable oils
used in fast-food preparations, most snack-foods, cookies, crackers, and sweet treats are also loaded with omega-6 fatty acids. Also,
our bodies synthesize eicosanoids from omega-6 fatty acids and these tend to increase inflammation, blood clotting, and cell
proliferation, while the hormones synthesized from omega-3 fatty acids have just the opposite effect.
While omega-6 fatty acids are essential, they can be harmful when they are out of balance with omega-3 fatty acids. Omega-6 fats
are required only in small quantities. Researchers believe that when omega-6 fats are out of balance with omega-3 fats in the diet
they diminish the effects of omega-3 fats and their benefits. This imbalance may elevate the risks for allergies, arthritis, asthma,
coronary heart disease, diabetes, and many types of cancer, autoimmunity, and neurodegenerative diseases, all of which are
believed to originate from some form of inflammation in the body.
1. High Blood Cholesterol: What You Need to Know. National Heart, Lung, and Blood Institute, National Institutes of Health.
NIH Publication. [Link]/health/publ...chol/[Link]. Updated June [Link] September 28, 2017. ↵
2. Dietary Reference Intakes: Macronutrients. Institute of Medicine.
[Link] Published 2006. Accessed September
28, 2017. ↵
3. Fish and Omega-3 Fatty Acids. American Heart Association. [Link]/Eat-smart/Articles/Fish-and-Omega-3-
Fatty-Acids. Updated March 24, 2017. Accessed October 5, 2017. ↵

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5.7: Tools for Change by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original
source: [Link]

5.7.3 [Link]
5.8: Lipids and the Food Industry
What is the first thing that comes to mind when you read ingredients such as “partially hydrogenated oil” and “hydrogenated oil”
on a food label? Do you think of heart disease, heart health, or atherosclerosis? Most people probably do not. As we uncover what
hydrogenation is and why manufacturers use it, you will be better equipped to adhere to healthier dietary choices and promote your
heart health.

Hydrogenation: The Good Gone Bad?

Food manufacturers are aware that fatty acids are susceptible to attack by oxygen molecules because their points of unsaturation
render them vulnerable in this regard. When oxygen molecules attack these points of unsaturation the modified fatty acid becomes
oxidized. The oxidation of fatty acids makes the oil rancid and gives the food prepared with it an unappetizing taste. Because oils
can undergo oxidation when stored in open containers, they must be stored in airtight containers and possibly be refrigerated to
minimize damage from oxidation. Hydrogenation poses a solution that food manufacturers prefer.
When lipids are subjected to hydrogenation, the molecular structure of the fat is altered. Hydrogenation is the process of adding
hydrogen to unsaturated fatty-acid chains, so that the hydrogen atoms are connected to the points of saturation and results in a more
saturated fatty acid. Liquid oils that once contained more unsaturated fatty acids become semisolid or solid (upon complete
hydrogenation) and behave like saturated fats. Oils initially contain polyunsaturated fatty acids. When the process of hydrogenation
is not complete, for example, not all carbon double bonds have been saturated the end result is a partially hydrogenated oil. The
resulting oil is not fully solid. Total hydrogenation makes the oil very hard and virtually unusable. Some newer products are now
using fully hydrogenated oil combined with nonhydrogenated vegetable oils to create a usable fat.
Manufacturers favor hydrogenation as a way to prevent oxidation of oils and ensure longer shelf life. Partially hydrogenated
vegetable oils are used in the fast food and processed food industries because they impart the desired texture and crispness to baked
and fried foods. Partially hydrogenated vegetable oils are more resistant to breakdown from extremely hot cooking temperatures.
Because hydrogenated oils have a high smoking point they are very well suited for frying. In addition, processed vegetable oils are
cheaper than fats obtained from animal sources, making them a popular choice for the food industry.
Trans fatty acids occur in small amounts in nature, mostly in dairy products. However, the trans fats that are used by the food
industry are produced from the hydrogenation process. Trans fats are a result of the partial hydrogenation of unsaturated fatty acids,
which cause them to have a trans configuration, rather than the naturally occurring cis configuration.

Health Implications of Trans Fats

No trans fats! Zero trans fats! We see these advertisements on a regular basis. So widespread is the concern over the issue that
restaurants, food manufacturers, and even fast-food establishments proudly tout either the absence or the reduction of these fats
within their products. Amid the growing awareness that trans fats may not be good for you, let’s get right to the heart of the matter.
Why are trans fats so bad?
Processing naturally occurring fats to modify their texture from liquid to semisolid and solid forms results in the development of
trans fats, which have been linked to an increased risk for heart disease. Trans fats are used in many processed foods such as
cookies, cakes, chips, doughnuts, and snack foods to give them their crispy texture and increased shelf life. However, because trans
fats can behave like saturated fats, the body processes them as if they were saturated fats. Consuming large amounts of trans fats
has been associated with tissue inflammation throughout the body, insulin resistance in some people, weight gain, and digestive
troubles. In addition, the hydrogenation process robs the person of the benefits of consuming the original oil because hydrogenation
destroys omega-3 and omega-6 fatty acids. The AHA states that, like saturated fats, trans fats raise LDL “bad cholesterol,” but
unlike saturated fats, trans fats lower HDL “good cholesterol.” The AHA advises limiting trans-fat consumption to less than 1
percent.
How can you benefit from this information? When selecting your foods, steer clear of anything that says “hydrogenated,”
“fractionally hydrogenated,” or “partially hydrogenated,” and read food labels in the following categories carefully:
cookies, crackers, cakes, muffins, pie crusts, pizza dough, and breads
stick margarines and vegetable shortening

5.8.1 [Link]
 premixed cake mixes, pancake mixes, and drink mixes
fried foods and hard taco shells
snack foods (such as chips), candy, and frozen dinners
Choose brands that don’t use trans fats and that are low in saturated fats.

Dietary-Fat Substitutes
In response to the rising awareness and concern over the consumption of trans fat, various fat replacers have been developed. Fat
substitutes aim to mimic the richness, taste, and smooth feel of fat without the same caloric content as fat. The carbohydrate-based
replacers tend to bind waterand thus dilute calories. Fat substitutes can also be made from proteins (for example, egg whites and
milk whey). However, these are not very stable and are affected by changes in temperature, hence their usefulness is somewhat
limited.

Tools for Change

One classic cinnamon roll can have 5 grams of trans fat, which is quite high for a single snack. Many packaged foods often have
their nutrient contents listed for a very small serving size—much smaller than what people normally consume—which can easily
lead you to eat many “servings.” Labeling laws allow foods containing trans fat to be labeled “trans-fat free” if there are fewer than
0.5 grams per serving. This makes it possible to eat too much trans fat when you think you’re not eating any at all because it is
labeled trans-fat free.
Always review the label for trans fat per serving. Check the ingredient list, especially the first three to four ingredients, for telltale
signs of hydrogenated fat such as partially or fractionated hydrogenated oil. The higher up the words “partially hydrogenated oil”
are on the list of ingredients, the more trans fat the product contains.
Measure out one serving and eat one serving only. An even better choice would be to eat a fruit or vegetable. There are no trans fats
and the serving size is more reasonable for similar calories. Fruits and vegetables are packed with water, fiber, and many vitamins,
minerals, phytonutrients, and antioxidants. At restaurants be aware that phrases such as “cooked in vegetable oil” might mean
hydrogenated vegetable oil, and therefore trans fat.

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5.8.2 [Link]
5.9: Lipids and Disease
Because heart disease, cancer, and stroke are the three leading causes of death in the United States, it is critical to address dietary
and lifestyle choices that will ultimately decrease risk factors for these diseases. According to the US Department of Health and
Human Services (HHS), the following risk factors are controllable: high blood pressure, high cholesterol, cigarette smoking,
diabetes, poor diet, physical inactivity, being overweight, and obesity.
In light of that, we present the following informational tips to help you define, evaluate, and implement healthy dietary choices to
last a lifetime. The amount and the type of fat that composes a person’s dietary profile will have a profound effect upon the way fat
and cholesterol is metabolized in the body.

Watch Out for Saturated Fat and Cholesterol

In proper amounts, cholesterol is a compound used by the body to sustain many important body functions. In excess, cholesterol is
harmful if it accumulates in the structures of the body’s vast network of blood vessels. High blood LDL and low blood HDL are
major indicators of blood cholesterol risk. The largest influence on blood cholesterol levels rests in the mix of saturated fat and
trans fat in the diet. According to the Harvard School of Public Health, for every extra 2 percent of calories from trans fat
consumed per day—about the amount found in a midsize order of French fries at a fast-food establishment—the risk of coronary
heart disease increases by 23 percent[1]. A buildup of cholesterol in the blood can lead to brittle blood vessels and a blockage of
blood flow to the affected area.
How saturated is the fat in your diet? Is it really necessary to eat saturated fat when the body makes all the saturated fat that it
needs? Saturated fats should fall into the “bad” category—the body does not demand this kind of fat and it is proven to be a
forerunner of cardiovascular disease. In the United States and other developed countries, populations acquire their saturated fat
content mostly from meat, seafood, poultry (with skin consumed), and whole-milk dairy products (cheese, milk, and ice cream).
Some plant foods are also high in saturated fats, including coconut oil, palm oil, and palm kernel oil.

Food Cholesterol’s Effect on Blood Cholesterol

Dietary cholesterol does have a small impact on overall blood cholesterol levels, but not as much as some people may think. The
average American female consumes 237 milligrams of dietary cholesterol per day and for males the figure is slightly higher—about
358 milligrams. Most people display little response to normal dietary cholesterol intake as the body responds by halting its own
synthesis of the substance in favor of using the cholesterol obtained through food. Genetic factors may also influence the way a
person’s body modifies cholesterol. The 2015-2020 US Dietary Guidelines suggest limiting saturated fats, thereby indirectly
limiting dietary cholesterol since foods that are high in cholesterol tend to be high in saturated fats also.

A Prelude to Disease
If left unchecked, improper dietary fat consumption can lead down a path to severe health problems. An increased level of lipids,
triglycerides, and cholesterol in the blood is called hyperlipidemia. Hyperlipidemia is inclusive of several conditions but more
commonly refers to high cholesterol and triglyceride levels. When blood lipid levels are high, any number of adverse health
problems may ensue. Consider the following:
Cardiovascular disease. According to the AHA, cardiovascular disease encompasses a variety of problems, many of which are
related to the process of atherosclerosis. Over time the arteries thicken and harden with plaque buildup, causing restricted or at
times low or no blood flow to selected areas of the body.
Heart attack. A heart attack happens when blood flow to a section of the heart is cut off due to a blood clot. Many have survived
heart attacks and go on to return to their lives and enjoy many more years of life on this earth. However, dietary and lifestyle
changes must be implemented to prevent further attacks.
Ischemic stroke. The most common type of stroke in the United States, ischemic stroke, occurs when a blood vessel in the brain
or leading to the brain becomes blocked, again usually from a blood clot. If part of the brain suffers lack of blood flow and/or
oxygen for three minutes or longer, brain cells will start to die.
Congestive heart failure. Sometimes referred to as heart failure, this condition indicates that the heart is not pumping blood as
well as it should. The heart is still working but it is not meeting the body’s demand for blood and oxygen. If left unchecked, it
can progress to further levels of malfunction.

5.9.1 [Link]
 Arrhythmia. This is an abnormal rhythm of the heart. The heart may beat above one hundred beats per minute (known as
tachycardia) or below sixty beats per minute (known as bradycardia), or the beats are not regular. The heart may not be able to
pump enough volume of blood to meet the body’s needs.
Heart valve problems. Stenosis is a condition wherein the heart valves become compromised in their ability to open wide
enough to allow proper blood flow. When the heart valves do not close tightly and blood begins to leak between chambers, this
is called regurgitation. When valves bulge or prolapse back into the upper chamber, this condition is called mitral valve
prolapse.
Obesity. Obesity is defined as the excessive accumulation of body fat. According to US Surgeon General Richard Carmona,
obesity is the fastest growing cause of death in America. The HHS reports that the number of adolescents who are overweight
has tripled since 1980 and the prevalence of the disease among younger children has doubled[2].
Obesity has been linked to increased risks of developing diabetes and heart disease. To help combat this problem important
dietary changes are necessary. Reducing the type and amount of carbohydrates and sugar consumed daily is critical. Limiting
the intake of saturated fats and trans fats, increasing physical activity, and eating fewer calories are all equally important in this
fight against obesity.

What You Can Do

Remember that saturated fats are found in large amounts in foods of animal origin. They should be limited within the diet.
Polyunsaturated fats are generally obtained from non-animal sources. While they are beneficial for lowering bad cholesterol they
also lower good cholesterol. They are better for you than saturated fats but are not to be consumed in excess. Monounsaturated fats
are of plant origin and are found in most nuts, seeds, seed oils, olive oil, canola oil, and legumes. Monounsaturated fats are
excellent because they not only lower bad cholesterol, but also they elevate the good cholesterol. Replace current dietary fats with
an increased intake of monounsaturated fats.
Choose whole-grain and high-fiber foods. Reduced risk for cardiovascular disease has been associated with diets that are high in
whole grains and fiber. Fiber also slows down cholesterol absorption. The AHA recommends that at least half of daily grain intake
should originate from whole grains. The Adequate Intake value for fiber is 14 grams per 1,000 kilocalories. These amounts are
based upon the amount of fiber that has been shown to reduce cardiovascular risk.
Do not be sedentary. Get more exercise on a regular basis. Increasing your energy expenditure by just twenty minutes of physical
activity at least three times per week will improve your overall health. Physical exercise can help you manage or prevent high
blood pressure and blood cholesterol levels. Regular activity raises HDL while at the same time decreases triglycerides and plaque
buildup in the arteries. Calories are burned consistently, making it easier to lose and manage weight. Circulation will improve, the
body will be better oxygenated, and the heart and blood vessels will function more efficiently.

Learning Activities
1. Fats and Cholesterol: Out with the Bad, In with the Good. Harvard School of Public Health.
[Link] -eat/fats-full-story/. Updated 2017. Accessed September 28,
2017. ↵
2. Childhood Obesity. US Department of Health and Human Services. [Link] Published
May 1, 2005. Accessed October 5, 2012. ↵

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platform.
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5.9.2 [Link]
5.10: Understanding Blood Cholesterol and Heart Attack Risk
Learning Objectives
Compare and contrast the roles of LDLs and HDLs in your body.
Explain the purpose of a blood lipid profile and identify healthy ranges.

You may have heard of the abbreviations LDL and HDL with respect to heart health. These abbreviations refer to low-density
lipoprotein (LDL) and high-density lipoprotein (HDL), respectively. Lipoproteins are characterized by size, density, and
composition. As the size of the lipoprotein increases, the density decreases. This means that HDL is smaller than LDL. Why are
they referred to as “good” and “bad” cholesterol? What should you know about these lipoproteins?

Major Lipoproteins
Recall that chylomicrons are transporters of fats throughout the watery environment within the body. After about ten hours of
circulating throughout the body, chylomicrons gradually release their triacylglycerols until all that is left of their composition is
cholesterol-rich remnants. These remnants are used as raw materials by the liver to formulate specific lipoproteins. Following is a
list of the various lipoproteins and their functions:
VLDLs. Very low-density lipoproteins are made in the liver from remnants of chylomicrons and transport triacylglycerols from
the liver to various tissues in the body. As the VLDLs travel through the circulatory system, the lipoprotein lipase strips the
VLDL of triacylglycerols. As triacylglycerol removal persists, the VLDLs become intermediate-density lipoproteins.
IDLs. Intermediate-density lipoproteins transport a variety of fats and cholesterol in the bloodstream and are a little under half
triacylglycerol in composition. While travelling in the bloodstream, cholesterol is gained from other lipoproteins while
circulating enzymes strip its phospholipid component. When IDLs return to the liver, they are transformed into low-density
lipoprotein.
LDLs. As low-density lipoproteins are commonly known as the “bad cholesterol” it is imperative that we understand their
function in the body so as to make healthy dietary and lifestyle choices. LDLs carry cholesterol and other lipids from the liver
to tissue throughout the body. LDLs are comprised of very small amounts of triacylglycerols, and house over 50 percent
cholesterol and cholesterol esters. How does the body receive the lipids contained therein? As the LDLs deliver cholesterol and
other lipids to the cells, each cell’s surface has receptor systems specifically designed to bind with LDLs. Circulating LDLs in
the bloodstream bind to these LDL receptors and are consumed. Once inside the cell, the LDL is taken apart and its cholesterol
is released. In liver cells these receptor systems aid in controlling blood cholesterol levels as they bind the LDLs. A deficiency
of these LDL binding mechanisms will leave a high quantity of cholesterol traveling in the bloodstream, which can lead to heart
disease or atherosclerosis. Diets rich in saturated fats will prohibit the LDL receptors. Thus, LDL receptors are critical for
regulating cholesterol levels.
HDLs. High-density lipoproteins are responsible for carrying cholesterol out of the bloodstream and into the liver, where it is
either reused or removed from the body with bile. HDLs have a very large protein composition coupled with low cholesterol
content (20 to 30 percent) compared to the other lipoproteins. Hence, these high-density lipoproteins are commonly called
“good cholesterol.”

Contrasting LDL and HDL

Heart attack and atherosclerosis are conditions often caused by cholesterol that has accumulated and thickened in the walls of
arteries. HDLs and LDLs are directly connected to these life-threatening ailments. By comparing and contrasting the roles each of
these lipoproteins serves in the health of heart and blood vessels, you will be able to construct and evaluate a plan of action for your
personal health. Consider the following lipoprotein facts:
LDL/HDL composition. LDL is approximately 25 percent protein and 75 percent cholesterol and other fats. LDL is bigger (yet
lighter) and richer in cholesterol than HDL. HDL is 50 percent protein and 50 percent cholesterol and other fats. HDL is
smaller, more dense, and richer in protein.
LDL/HDL function. LDLs carry cholesterol into cells for normal usage, but LDLs can also deposit cholesterol into the walls of
blood vessels, which can lead to harmful disease. HDLs scavenge excess cholesterol from the cells, tissues, and blood vessels

5.10.1 [Link]
 and deliver these back to the liver, where these are either reused or excreted.
LDL/HDL and inflammation. LDLs carry lipids that are proinflammatory and may contribute to heart disease. HDLs transport
lipids that are anti-inflammatory and may reduce the occurrence of heart disease.
LDL/HDL warnings. High LDL values warn of increased health risks for heart disease, while high HDL values indicate a
reduced risk for heart disease.
Oxidized LDL. LDLs become more dangerous when oxidized. Oxidation is defined as the loss of electrons between two
substances via a chemical reaction. If an LDL oxidation occurs, the oxidized LDL is left unstable. Oxidized LDL can speed up
the process of plaque formation in the arteries. It is believed to hasten the deposition of cholesterol into the arterial walls and to
induce a chronic inflammatory effect throughout the body’s vast network of vessels. This activity promotes atherosclerosis and
significantly increases risks for heart attack or stroke.

Blood Cholesterol Recommendations

For healthy total blood cholesterol, the desired range you would want to maintain is under 200 mg/dL. More specifically, when
looking at individual lipid profiles, a low amount of LDL and a high amount of HDL prevents excess buildup of cholesterol in the
arteries and wards off potential health hazards. An LDL level of less than 100 milligrams per deciliter is ideal while an LDL level
above 160 milligrams per deciliter would be considered high. In contrast, a low value of HDL is a telltale sign that a person is
living with major risks for disease. Values of less than 40 milligrams per deciliter for men and 50 milligrams per deciliter for
women mark a risk factor for developing heart disease. In short, elevated LDL blood lipid profiles indicate an increased risk of
heart attack, while elevated HDL blood lipid profiles indicate a reduced risk.
The University of Maryland Medical Center reports that omega-3 fatty acids promote lower total cholesterol and lower
triacylglycerols in people with high cholesterol (University of Maryland Medical Center. “Omega-3 fatty acids.”) It is suggested
that people consume omega-3 fatty acids such as alpha-linolenic acid in their diets regularly. Polyunsaturated fatty acids are
especially beneficial to consume because they both lower LDL and elevate HDL, thus contributing to healthy blood cholesterol
levels. The study also reveals that saturated and trans fatty acids serve as catalysts for the increase of LDL cholesterol. Additionally,
trans fatty acids raise HDL levels, which can impact negatively on total blood cholesterol.

Tools for Change

Being conscious of the need to reduce cholesterol means limiting the consumption of saturated fats and trans fats. Remember
that saturated fats found in some meat, whole-fat dairy products, and tropical oils elevate your total cholesterol. Trans fats,
such as the ones often found in margarines, processed cookies, pastries, crackers, fried foods, and snack foods also elevate your
cholesterol levels. Read and select from the following suggestions as you plan ahead:
Soluble fiber reduces cholesterol absorption in the bloodstream. Try eating more oatmeal, oat bran, kidney beans, apples,
pears, citrus fruits, barley, and prunes.
Fatty fish are heart-healthy due to high levels of omega-3 fatty acids that reduce inflammation and lower cholesterol levels.
Consume mackerel, lake trout, herring, sardines, tuna, salmon, and halibut. Grilling or baking is best to avoid unhealthy
trans fats that could be added from frying oil.
Walnuts, almonds, peanuts, hazelnuts, pecans, some pine nuts, and pistachios all contain high levels of unsaturated fatty
acids that aid in lowering LDL. Make sure the nuts are raw and unsalted. Avoid sugary or salty nuts. One ounce each day is
a good amount.
Olive oil contains a strong mix of antioxidants and monounsaturated fat, and may lower LDL while leaving HDL intact.
Two tablespoons per day in place of less healthy saturated fats may contribute to these heart-healthy effects without adding
extra calories. Extra virgin olive oil promises a greater effect, as the oil is minimally processed and contains more heart-
healthy antioxidants.

Testing Your Lipid Profile

The danger of consuming foods rich in cholesterol and saturated and trans fats cannot be overemphasized. Regular testing can
provide the foreknowledge necessary to take action to help prevent any life-threatening events.

5.10.2 [Link]
Current guidelines recommend testing for anyone over age twenty. If there is family history of high cholesterol, your healthcare
provider may suggest a test sooner than this. Testing calls for a blood sample to be drawn after nine to twelve hours of fasting for
an accurate reading. (By this time, most of the fats ingested from the previous meal have circulated through the body and the
concentration of lipoproteins in the blood will have stabilized.)
According to the National Institutes of Health (NIH), the following total cholesterol values are used to target treatment:National
Heart, Lung, and Blood Institute, National Institutes of Health. “High Blood Cholesterol: What You Need to Know.” NIH
Publication No. 05-3290. (Revised June 2005). Section 2.01. [Link]/health/publ...chol/[Link].
Desirable. Under 200 milligrams per deciliter
Borderline high. 200–239 milligrams per deciliter
High risk. 240 milligrams per deciliter and up
According to the NIH, the following desired values are used to measure an overall lipid profile:
LDL. Less than 160 milligrams per deciliter (if you have heart disease or diabetes, less than 100 milligrams per deciliter)
HDL. Greater than 40–60 milligrams per deciliter
Triacylglycerols. 10–150 milligrams per deciliter
VLDL. 2–38 milligrams per deciliter

What happens during a heart attack? - K…

K…

Video : What happens during a heart attack? Krishna Sudhir

([Link] Approximately seven million people
around the world die from heart attacks every year. And cardiovascular
disease, which causes heart attacks and other problems like strokes, is the
world’s leading killer. So what causes a heart attack? Krishna Sudhir examines
the leading causes and treatments of this deadly disease.

Key Takeaways
Some of the major lipoproteins are VLDL, IDL, LDL, and HDL.
VLDL delivers triacylglycerols and other lipids to the body’s tissues and slowly becomes IDL. The liver uses IDL to create
LDL, the main transporter of cholesterol.
LDL, or “bad” cholesterol, has low protein composition and high cholesterol content. High levels of LDL have been shown to
increase the risks for heart disease.
HDL or “good’’ cholesterol has a larger proportion of protein and a small cholesterol composition. HDL scavenges excess
cholesterol and returns it to the liver for reuse or disposal. A high level of HDL reduces the risk for heart disease.
It is important to maintain a healthy lipid profile with values as recommended by the NIH in order to minimize the risk of heart
disease. Consuming omega-3 fatty acids can help maintain a healthy blood lipid profile.

Discussion Starters
1. Summarize the roles of LDL and HDL. Explain why LDL is termed “bad” cholesterol and why HDL is termed “good”
cholesterol.

5.10.3 [Link]
 2. Explain oxidation and how it affects LDL and contributes to heart disease.
3. Describe the procedure and blood test for testing your lipid profile.
4. Recall the desired lipid values set out by the NIH. Identify the desired total cholesterol, LDL, HDL, VLDL, and triacylglycerol
values.
5. How has learning this information affected your motivation to eat a more healthy diet?

5.10: Understanding Blood Cholesterol and Heart Attack Risk is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated
by LibreTexts.

5.10.4 [Link]
5.11: A Personal Choice about Lipids
A Guide to Making Sense of Dietary Fat
On your next trip to the grocery store prepare yourself to read all food labels carefully and to seriously consider everything that
goes into your shopping cart. Create a shopping list and divide your list into columns for “Best,” “Better,” “Good,” “Least
Desirable,” and “Infrequent Foods.” As you refine your sense of dietary fat, here are key points to bear in mind:
Shopping for groceries. Don’t be bombarded with gratuitous grams of saturated fats and empty grams of trans fats. Read and
decipher food labels carefully so that you know exactly what types of fat a food item contains and how much fat it will
contribute to your overall fat intake. For snacks and daily eating, gravitate toward foods that are lowest in or absent of harmful
trans fats. Restrict other foods to occasional usage based upon their fat content. For example, if selecting prepared foods, choose
the ones without high-fat sauces in favor of adding your own flavorings. If selecting precooked meats, avoid those that are fried,
coated, or prepared in high-fat sauces. A popular and healthy precooked meat food choice is the rotisserie chicken that most
supermarkets carry. When selecting meats be aware of the need to compare different cuts—notice their fat content, color, and
marbling. Higher-fat meats tend to have whiter fat marbled throughout. Choose lean cuts and white meat as these are lower in
saturated fat. Always choose plenty of fresh fruits, vegetables, nuts, and seeds, as their phytosterols are a good competitor for
cholesterol. Keep a collection of nuts in your freezer that can be added to your salads, stir-fry, one-dish foods, soups, desserts,
and yogurts.
Appearance. Saturated and trans fats are not good for you and must be placed in your “Least Desirable” column because they
increase cholesterol levels and put you at risk for heart disease. Monounsaturated and polyunsaturated fats are better choices to
replace these undesirable fats. The key in identifying the “Best” or “Better” fats from the “Least Desirable” fats while you shop
is based upon appearance. When choosing fats remember that saturated fats and trans fats are solid at room temperature; think
of butter. Monounsaturated and polyunsaturated fats are liquid at room temperature; think of vegetable oil.
Try to eliminate as much trans fat as possible from your food selections. Avoid commercially baked goods and fast foods.
Make these your “Infrequent Foods.”
Choose unsaturated fats. Fatty fish, walnuts, flaxseeds, flaxseed oil, and canola oil all have good health benefits and should be
on the “Best,” “Better,” and “Good” fat lists. They each provide essential omega-3 fatty acids necessary for overall body health.
To derive the most benefit from including these foods, do not add them to an existing diet full of fat. Use these to replace the
“Least Desirable” fats that are being removed from the diet.
Limit saturated fat intake. Reduce red meat consumption, processed meats, and whole-fat dairy products. To reduce full-fat
dairy items try their low-fat or nonfat counterparts such as mozzarella cheese.
Low fat does not equal healthy. Remember, a fat-free label does not provide you with a license to consume all the calories you
desire. There will be consequences to your weight and your overall health. Common replacements for fat in many fat-free foods
are refined carbohydrates, sugar, and calories. Too much of these ingredients can also cause health problems. Choose and
consume wisely.
A “better-fat” diet will successfully support weight loss. While cutting “Least Desirable” fat calories are vital to weight loss,
remember that “Better” fats are filling and just a handful of nuts can curb an appetite to prevent overeating.
Consume omega-3 fats each day. For optimal health and disease prevention include a moderate serving of fish, walnuts,
ground flaxseeds, flaxseed oil, or soybean oil in your diet every day.
How much saturated fat is too much? Your goal is to keep your intake of saturated fat to no more than 10 percent of your
total dietary calories on a daily basis. Thus, it is important to learn to reduce the intake of foods high in saturated fat. High-fat
foods can be consumed but they must fall within the overall goal for a person’s fat allowance for the day.
Home cooking. Limit the use of saturated fats in home preparation of meals. Instead of butter try spreads made from
unsaturated oils such as canola or olive oils and the use of cooking sprays. Couple this with the use of herbs and spices to add
flavor. Avoid using high-fat meat gravies, cheese, and cream sauces. Limit adding extras to foods such as butter on a baked
potato. Use nonfat sour cream instead. Grill, bake, stir-fry, roast, or bake your foods. Never fry in solid fats such as butter or
shortening. Marinate foods to be grilled in fruit juices and herbs. Instead of relying upon commercial salad dressings, learn to
make your own top-quality dressing from cold-pressed olive oil, flaxseed oil, or sesame oil.

5.11.1 [Link]
 Make sure the fat is flavorful. Adding flavor to food is what makes the eating experience enjoyable. Why not choose
unsaturated fats and oils that have strong flavors? In this way you will add good flavor to your meals but use less fat in the
process. Some examples are sesame oil, peanut oil, and peanut butter. Replace less flavorful cheeses with small amounts of
strongly flavored cheeses such as romano, parmesan, and asiago.
Now that you have gained a wealth of information and food for thought to enable you to make changes to your dietary pattern we
hope that your desire to pursue a healthier lifestyle has been solidified. While we realize that making grand strides in this direction
may be awkward at first, even the smallest of accomplishments can produce noticeable results that will spur you on and perhaps
spark the interest of friends and family to join you in this health crusade.
Becoming aware of the need to limit your total fat intake will facilitate your ability to make better choices. In turn, making better
dietary choices requires gaining knowledge. As you understand that your food choices not only impact your personal physical
health but also the delicate balance of our ecosystem, we are confident that you will successfully adapt to the dynamics of the ever-
changing global food supply. Remember, the food choices you make today will benefit you tomorrow and into the years to come.

Learning Activities
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LibreTexts platform.
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5.11.2 [Link]
5.E: Lipids (Exercises)
It’s Your Turn
1. Provide examples of three foods that are rich in unsaturated fats.
2. Assume you are reluctant to eat fish. Name three other sources of omega-3 fats.
3. Your friend tends to feel cold a lot of the time, is often tired, and has developed sores on her skin. Based on the content in this
chapter, identify a nutritional reason for this condition.
4. Explain the role of lipids in your overall health.
5. Discuss the role of trans (hydrogenated) fats for both consumer and food producer.

Apply It
1. Make a chart of the three main types of lipids, their specific functions in the body, and where they are found.
2. Diagram the steps in lipid digestion and absorption.
3. Create a blood lipid profile with healthy ranges.

Expand Your Knowledge

1. You’re making a concerted effort to begin eating more foods that will promote good health. Turn your attention to omega-3
fatty acids. What will you incorporate into your diet?
2. Obesity rates in the United States have more than tripled since 1980. At the same time, “low fat” advertising is all over the
news. How would you explain this?
3. Calculate your 10 Year Risk for Heart Attack or Stroke using the following tool: [Link] Check with
three members of your family or close friends. What does this tell you about their risk?

5.E: Lipids (Exercises) is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

5.E.1 [Link]
 CHAPTER OVERVIEW

6: Protein
Learning Objectives
By the end of this chapter, you will be able to:
Describe the role and structure of proteins
Describe the functions of proteins in the body
Describe the consequences of protein imbalance

6.1: Introduction to Protein

6.2: Defining Protein
6.3: The Role of Proteins in Foods- Cooking and Denaturation
6.4: Protein Digestion and Absorption
6.5: Protein’s Functions in the Body
6.6: Diseases Involving Proteins
6.7: Proteins in a Nutshell
6.8: Proteins, Diet, and Personal Choices

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Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.

1
6.1: Introduction to Protein
He pūkoʻa kani ʻāina
A coral reef that grows into an island

Ahi poke by Arnold Gatilao / CC BY 2.0

Protein is a vital constituent of all organs in the body and is required to perform a vast variety of functions. Therefore, protein is an
essential nutrient that must be consumed in the diet. Many Pacific Island societies such as the Native Hawaiians accompanied their
starch meals with some type of meat or seafood. In Hawai‘i, a typical meal consisted of taro or poi accompanied with fish. Fish is
known to be a complete protein source which means that all nine essential amino acids are present in the recommended amounts
needed. Native Hawaiians ate their fish raw, cooked, salted or dried. If the fish was to be eaten raw, it was prepared by mashing the
flesh with the fingers (lomi) to soften the meat and allow the salt to penetrate the flesh deeper. If the fish was not soft enough to
lomi, it was cut into chunks or slices or left whole. Today, the most popular and contemporary prepared way of eating fish is known
as poke. Poke, which means “cut up pieces” in Hawaiian, is chopped up chunks of fish that can be seasoned in a variety of different
ways. Some common ways of seasoning include salt, shoyu (soy sauce), limu (seaweed), garlic, and onions. Any type of fish can be
used to make poke but ahi (tuna) fish is typically the most desirable option.[1]
Your protein-rich muscles allow for body strength and movement, which enable you to enjoy many activities.

Figure : William Hook

[Link]
1. Fish Preparation/Eating. [Link]. [Link] Updated 2017. Accessed
October 30, 2017. ↵

6.1.1 [Link]
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Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts
platform.
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source: [Link]

6.1.2 [Link]
6.2: Defining Protein
Protein makes up approximately 20 percent of the human body and is present in every single cell. The word protein is a Greek
word, meaning “of utmost importance.” Proteins are called the workhorses of life as they provide the body with structure and
perform a vast array of functions. You can stand, walk, run, skate, swim, and more because of your protein-rich muscles. Protein is
necessary for proper immune system function, digestion, and hair and nail growth, and is involved in numerous other body
functions. In fact, it is estimated that more than one hundred thousand different proteins exist within the human body. In this
chapter you will learn about the components of protein, the important roles that protein serves within the body, how the body uses
protein, the risks and consequences associated with too much or too little protein, and where to find healthy sources of it in your
diet.

What Is Protein?
Proteins, simply put, are macromolecules composed of amino acids. Amino acids are commonly called protein’s building blocks.
Proteins are crucial for the nourishment, renewal, and continuance of life. Proteins contain the elements carbon, hydrogen, and
oxygen just as carbohydrates and lipids do, but proteins are the only macronutrient that contains nitrogen. In each amino acid the
elements are arranged into a specific conformation around a carbon center. Each amino acid consists of a central carbon atom
connected to a side chain, a hydrogen, a nitrogen-containing amino group, and a carboxylic acid group—hence the name “amino
acid.” Amino acids differ from each other by which specific side chain is bonded to the carbon center.

Figure : Some Phytochemical’s Obtained from Diet and Their

Related Functions: Amino Acid Structure. Image by Allison Calabrese / CC BY 4.0
Amino acids contain four elements. The arrangement of elements around the carbon center is the same for all amino acids. Only the
side chain (R) differs.

It’s All in the Side Chain

The side chain of an amino acid, sometimes called the “R” group, can be as simple as one hydrogen bonded to the carbon center, or
as complex as a six-carbon ring bonded to the carbon center. Although each side chain of the twenty amino acids is unique, there
are some chemical likenesses among them. Therefore, they can be classified into four different groups. These are nonpolar, polar,
acidic, and basic.

6.2.1 [Link]
 Figure : The Different Groups of Amino
Acids. Amino acids are classified into four groups. These are nonpolar, polar, acidic, and basic.

Essential and Nonessential Amino Acids

Amino acids are further classified based on nutritional aspects. Recall that there are twenty different amino acids, and we require
all of them to make the many different proteins found throughout the body. Eleven of these are called nonessential amino acids
because the body can synthesize them. However, nine of the amino acids are called essential amino acids because we cannot
synthesize them either at all or in sufficient amounts. These must be obtained from the diet. Sometimes during infancy, growth, and
in diseased states the body cannot synthesize enough of some of the nonessential amino acids and more of them are required in the
diet. These types of amino acids are called conditionally essential amino acids. The nutritional value of a protein is dependent on
what amino acids it contains and in what quantities.
Table : Essential and Nonessential Amino Acids

Essential Nonessential

Histidine Alanine

Isoleucine Arginine*

Leucine Asparagine

Lysine Aspartic acid

Methionine Cysteine*

Phenylalanine Glutamic acid

Threonine Glutamine*

Tryptophan Glycine*

Valine Proline*

Serine

Tyrosine*

*Conditionally essential

The Many Different Types of Proteins

As discussed, there are over one hundred thousand different proteins in the human body. Different proteins are produced because
there are twenty types of naturally occurring amino acids that are combined in unique sequences to form polypeptides. These
polypeptide chains then fold into a three-dimensional shape to form a protein (see Figure 6.3). Additionally, proteins come in many

6.2.2 [Link]
different sizes. The hormone insulin, which regulates blood glucose, is composed of only fifty-one amino acids; whereas collagen,
a protein that acts like glue between cells, consists of more than one thousand amino acids. Titin is the largest known protein. It
accounts for the elasticity of muscles, and consists of more than twenty-five thousand amino acids! The abundant variations of
proteins are due to the unending number of amino acid sequences that can be formed. To compare how so many different proteins
can be designed from only twenty amino acids, think about music. All of the music that exists in the world has been derived from a
basic set of seven notes C, D, E, F, G, A, B and variations thereof. As a result, there is a vast array of music and songs all composed
of specific sequences from these basic musical notes. Similarly, the twenty amino acids can be linked together in an extraordinary
number of sequences, much more than are possible for the seven musical notes to create songs. As a result, there are enormous
variations and potential amino acid sequences that can be created. For example, if an amino acid sequence for a protein is 104
amino acids long the possible combinations of amino acid sequences is equal to 20104, which is 2 followed by 135 zeros!

Figure : The Formation of Polypeptides. Image by Allison

Calabrese / CC BY 4.0

Building Proteins with Amino Acids

The building of a protein consists of a complex series of chemical reactions that can be summarized into three basic steps:
transcription, translation, and protein folding. The first step in constructing a protein is the transcription (copying) of the genetic
information in double-stranded deoxyribonucleic acid (DNA) into the single-stranded, messenger macromolecule ribonucleic acid
(RNA). RNA is chemically similar to DNA, but has two differences; one is that its backbone uses the sugar ribose and not
deoxyribose; and two, it contains the nucleotide base uracil, and not thymidine. The RNA that is transcribed from a given piece of
DNA contains the same information as that DNA, but it is now in a form that can be read by the cellular protein manufacturer
known as the ribosome. Next, the RNA instructs the cells to gather all the necessary amino acids and add them to the growing
protein chain in a very specific order. This process is referred to as translation. The decoding of genetic information to synthesize a
protein is the central foundation of modern biology.

6.2.3 [Link]
 Figure : Steps for Building a Protein
Building a protein involves three steps: transcription, translation, and folding. During translation each amino acid is connected to
the next amino acid by a special chemical bond called a peptide bond. The peptide bond forms between the carboxylic acid group
of one amino acid and the amino group of another, releasing a molecule of water. The third step in protein production involves
folding it into its correct shape. Specific amino acid sequences contain all the information necessary to spontaneously fold into a
particular shape. A change in the amino acid sequence will cause a change in protein shape. Each protein in the human body differs
in its amino acid sequence and consequently, its shape. The newly synthesized protein is structured to perform a particular function
in a cell. A protein made with an incorrectly placed amino acid may not function properly and this can sometimes cause disease.

Protein Organization
Protein’s structure enables it to perform a variety of functions. Proteins are similar to carbohydrates and lipids in that they are
polymers of simple repeating units; however, proteins are much more structurally complex. In contrast to carbohydrates, which
have identical repeating units, proteins are made up of amino acids that are different from one another. Furthermore, a protein is
organized into four different structural levels.
Primary: The first level is the one-dimensional sequence of amino acids that are held together by peptide bonds. Carbohydrates
and lipids also are one-dimensional sequences of their respective monomers, which may be branched, coiled, fibrous, or
globular, but their conformation is much more random and is not organized by their sequence of monomers.
Secondary: The second level of protein structure is dependent on the chemical interactions between amino acids, which cause
the protein to fold into a specific shape, such as a helix (like a coiled spring) or sheet.
Tertiary: The third level of protein structure is three-dimensional. As the different side chains of amino acids chemically
interact, they either repel or attract each other, resulting in the folded structure. Thus, the specific sequence of amino acids in a
protein directs the protein to fold into a specific, organized shape.
Quaternary: The fourth level of structure is achieved when protein fragments called peptides combine to make one larger
functional protein. The protein hemoglobin is an example of a protein that has quaternary structure. It is composed of four
peptides that bond together to form a functional oxygen carrier.
A protein’s structure also influences its nutritional quality. Large fibrous protein structures are more difficult to digest than smaller
proteins and some, such as keratin, are indigestible. Because digestion of some fibrous proteins is incomplete, not all of the amino
acids are absorbed and available for the body to utilize, thereby decreasing their nutritional value.

6.2.4 [Link]
 Figure : The Four Structural Levels of Proteins. Image by OpenStax / CC
BY 4.0

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6.2.5 [Link]
6.3: The Role of Proteins in Foods- Cooking and Denaturation
In addition to having many vital functions within the body, proteins perform different roles in our foods by adding certain
functional qualities to them. Protein provides food with structure and texture and enables water retention. For example, proteins
foam when agitated. (Picture whisking egg whites to make angel food cake. The foam bubbles are what give the angel food cake its
airy texture.) Yogurt is another good example of proteins providing texture. Milk proteins called caseins coagulate, increasing
yogurt’s thickness. Cooked proteins add some color and flavor to foods as the amino group binds with carbohydrates and produces
a brown pigment and aroma. Eggs are between 10 and 15 percent protein by weight. Most cake recipes use eggs because the egg
proteins help bind all the other ingredients together into a uniform cake batter. The proteins aggregate into a network during mixing
and baking that gives cake structure.

Figure : Image by Annie Spratt on [Link] / CC0

Protein Denaturation: Unraveling the Fold

When a cake is baked, the proteins are denatured. Denaturation refers to the physical changes that take place in a protein exposed to
abnormal conditions in the environment. Heat, acid, high salt concentrations, alcohol, and mechanical agitation can cause proteins
to denature. When a protein denatures, its complicated folded structure unravels, and it becomes just a long strand of amino acids
again. Weak chemical forces that hold tertiary and secondary protein structures together are broken when a protein is exposed to
unnatural conditions. Because proteins’ function is dependent on their shape, denatured proteins are no longer functional. During
cooking the applied heat causes proteins to vibrate. This destroys the weak bonds holding proteins in their complex shape (though
this does not happen to the stronger peptide bonds). The unraveled protein strands then stick together, forming an aggregate (or
network).

Figure : Protein Denaturation. When a

protein is exposed to a different environment, such as increased temperature, it unfolds into a single strand of amino acids.

6.3.1 [Link]
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6.3: The Role of Proteins in Foods- Cooking and Denaturation by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is
licensed CC BY-NC-SA 4.0. Original source: [Link]

6.3.2 [Link]
6.4: Protein Digestion and Absorption
How do the proteins from foods, denatured or not, get processed into amino acids that cells can use to make new proteins? When
you eat food the body’s digestive system breaks down the protein into the individual amino acids, which are absorbed and used by
cells to build other proteins and a few other macromolecules, such as DNA. We previously discussed the general process of food
digestion, let’s follow the specific path that proteins take down the gastrointestinal tract and into the circulatory system (Figure
). Eggs are a good dietary source of protein and will be used as our example to describe the path of proteins in the processes of
digestion and absorption. One egg, whether raw, hard-boiled, scrambled, or fried, supplies about six grams of protein.

Figure : Digestion and

Absorption of Protein. Image by Allison Calabrese / CC BY 4.0

From the Mouth to the Stomach

Unless you are eating it raw, the first step in egg digestion (or any other protein food) involves chewing. The teeth begin the
mechanical breakdown of the large egg pieces into smaller pieces that can be swallowed. The salivary glands provide some saliva
to aid swallowing and the passage of the partially mashed egg through the esophagus. The mashed egg pieces enter the stomach
through the esophageal sphincter. The stomach releases gastric juices containing hydrochloric acid and the enzyme, pepsin, which
initiate the breakdown of the protein. The acidity of the stomach facilitates the unfolding of the proteins that still retain part of their
three-dimensional structure after cooking and helps break down the protein aggregates formed during cooking. Pepsin, which is
secreted by the cells that line the stomach, dismantles the protein chains into smaller and smaller fragments. Egg proteins are large
globular molecules and their chemical breakdown requires time and mixing. The powerful mechanical stomach contractions churn
the partially digested protein into a more uniform mixture called chyme. Protein digestion in the stomach takes a longer time than
carbohydrate digestion, but a shorter time than fat digestion. Eating a high-protein meal increases the amount of time required to
sufficiently break down the meal in the stomach. Food remains in the stomach longer, making you feel full longer.

From the Stomach to the Small Intestine

The stomach empties the chyme containing the broken down egg pieces into the small intestine, where the majority of protein
digestion occurs. The pancreas secretes digestive juice that contains more enzymes that further break down the protein fragments.
The two major pancreatic enzymes that digest proteins are chymotrypsin and trypsin. The cells that line the small intestine release
additional enzymes that finally break apart the smaller protein fragments into the individual amino acids. The muscle contractions
of the small intestine mix and propel the digested proteins to the absorption sites. In the lower parts of the small intestine, the
amino acids are transported from the intestinal lumen through the intestinal cells to the blood. This movement of individual amino

6.4.1 [Link]
acids requires special transport proteins and the cellular energy molecule, adenosine triphosphate (ATP). Once the amino acids are
in the blood, they are transported to the liver. As with other macronutrients, the liver is the checkpoint for amino acid distribution
and any further breakdown of amino acids, which is very minimal. Recall that amino acids contain nitrogen, so further catabolism
of amino acids releases nitrogen-containing ammonia. Because ammonia is toxic, the liver transforms it into urea, which is then
transported to the kidney and excreted in the urine. Urea is a molecule that contains two nitrogens and is highly soluble in water.
This makes it a good choice for transporting excess nitrogen out of the body. Because amino acids are building blocks that the body
reserves in order to synthesize other proteins, more than 90 percent of the protein ingested does not get broken down further than
the amino acid monomers.

Amino Acids Are Recycled

Just as some plastics can be recycled to make new products, amino acids are recycled to make new proteins. All cells in the body
continually break down proteins and build new ones, a process referred to as protein turnover. Every day over 250 grams of protein
in your body are dismantled and 250 grams of new protein are built. To form these new proteins, amino acids from food and those
from protein destruction are placed into a “pool.” Though it is not a literal pool, when an amino acid is required to build another
protein it can be acquired from the additional amino acids that exist within the body. Amino acids are used not only to build
proteins, but also to build other biological molecules containing nitrogen, such as DNA, RNA, and to some extent to produce
energy. It is critical to maintain amino acid levels within this cellular pool by consuming high-quality proteins in the diet, or the
amino acids needed for building new proteins will be obtained by increasing protein destruction from other tissues within the body,
especially muscle. This amino acid pool is less than one percent of total body-protein content. Thus, the body does not store protein
as it does with carbohydrates (as glycogen in the muscles and liver) and lipids (as triglycerides in adipose tissue).

Figure : Options For Amino Acid Use In

The Human Body. Image by Allison Calabrese / CC BY 4.0
Amino acids in the cellular pool come from dietary protein and from the destruction of cellular proteins. The amino acids in this
pool need to be replenished because amino acids are outsourced to make new proteins, energy, and other biological molecules.

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Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
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4.0. Original source: [Link]

6.4.2 [Link]
6.5: Protein’s Functions in the Body

Figure : Proteins are the “workhorses” of

the body and participate in many bodily functions. Proteins come in all sizes and shapes and each is specifically structured for its
particular function.

Structure and Motion

More than one hundred different structural proteins have been discovered in the human body, but the most abundant by far is
collagen, which makes up about 6 percent of total body weight. Collagen makes up 30 percent of bone tissue and comprises large
amounts of tendons, ligaments, cartilage, skin, and muscle. Collagen is a strong, fibrous protein made up of mostly glycine and
proline. Within its quaternary structure three peptide strands twist around each other like a rope and then these collagen ropes
overlap with others. This highly ordered structure is even stronger than steel fibers of the same size. Collagen makes bones strong,
but flexible. Collagen fibers in the skin’s dermis provide it with structure, and the accompanying elastin protein fibrils make it
flexible. Pinch the skin on your hand and then let go; the collagen and elastin proteins in skin allow it to go back to its original
shape. Smooth-muscle cells that secrete collagen and elastin proteins surround blood vessels, providing the vessels with structure
and the ability to stretch back after blood is pumped through them. Another strong, fibrous protein is keratin, which is what skin,
hair, and nails are made of. The closely packed collagen fibrils in tendons and ligaments allow for synchronous mechanical
movements of bones and muscle and the ability of these tissues to spring back after a movement is complete.

6.5.1 [Link]
 Figure : Collagen Structure. Collagen Triple Helix by
Nevit Dilmen / CC BY-SA 3.0

Enzymes
Although proteins are found in the greatest amounts in connective tissues such as bone, their most extraordinary function is as
enzymes. Enzymes are proteins that conduct specific chemical reactions. An enzyme’s job is to provide a site for a chemical
reaction and to lower the amount of energy and time it takes for that chemical reaction to happen (this is known as “catalysis”). On
average, more than one hundred chemical reactions occur in cells every single second and most of them require enzymes. The liver
alone contains over one thousand enzyme systems. Enzymes are specific and will use only particular substrates that fit into their
active site, similar to the way a lock can be opened only with a specific key. Nearly every chemical reaction requires a specific
enzyme. Fortunately, an enzyme can fulfill its role as a catalyst over and over again, although eventually it is destroyed and rebuilt.
All bodily functions, including the breakdown of nutrients in the stomach and small intestine, the transformation of nutrients into
molecules a cell can use, and building all macromolecules, including protein itself, involve enzymes (Figure ).

Figure : Enzymes Role in Carbohydrate

Digestion. Image by Allison Calabrese / CC BY 4.0

Hormones
Proteins are responsible for hormone synthesis. Hormones are the chemical messages produced by the endocrine glands. When an
endocrine gland is stimulated, it releases a hormone. The hormone is then transported in the blood to its target cell, where it
communicates a message to initiate a specific reaction or cellular process. For instance, after you eat a meal, your blood glucose
levels rise. In response to the increased blood glucose, the pancreas releases the hormone insulin. Insulin tells the cells of the body
that glucose is available and to take it up from the blood and store it or use it for making energy or building macromolecules. A
major function of hormones is to turn enzymes on and off, so some proteins can even regulate the actions of other proteins. While
not all hormones are made from proteins, many of them are.

6.5.2 [Link]
Fluid and Acid-Base Balance
Proper protein intake enables the basic biological processes of the body to maintain the status quo in a changing environment. Fluid
balance refers to maintaining the distribution of water in the body. If too much water in the blood suddenly moves into a tissue, the
results are swelling and, potentially, cell death. Water always flows from an area of high concentration to one of a low
concentration. As a result, water moves toward areas that have higher concentrations of other solutes, such as proteins and glucose.
To keep the water evenly distributed between blood and cells, proteins continuously circulate at high concentrations in the blood.
The most abundant protein in blood is the butterfly-shaped protein known as albumin. Albumin’s presence in the blood makes the
protein concentration in the blood similar to that in cells. Therefore, fluid exchange between the blood and cells is not in the
extreme, but rather is minimized to preserve the status quo.

Figure : The Protein Albumin. PDB 1o9x EBI by Jawahar

Swaminathan and MSD staff at the European Bioinformatics Institute / Public Domain The butterfly-shaped protein, albumin, has
many functions in the body including maintaining fluid and acid-base balance and transporting molecules.
Protein is also essential in maintaining proper pH balance (the measure of how acidic or basic a substance is) in the blood. Blood
pH is maintained between 7.35 and 7.45, which is slightly basic. Even a slight change in blood pH can affect body functions.
Recall that acidic conditions can cause protein denaturation, which stops proteins from functioning. The body has several systems
that hold the blood pH within the normal range to prevent this from happening. One of these is the circulating albumin. Albumin is
slightly acidic, and because it is negatively charged it balances the many positively charged molecules, such as protons (H+),
calcium, potassium, and magnesium which are also circulating in the blood. Albumin acts as a buffer against abrupt changes in the
concentrations of these molecules, thereby balancing blood pH and maintaining the status quo. The protein hemoglobin also
participates in acid-base balance by binding and releasing protons.

Transport
Albumin and hemoglobin also play a role in molecular transport. Albumin chemically binds to hormones, fatty acids, some
vitamins, essential minerals, and drugs, and transports them throughout the circulatory system. Each red blood cell contains
millions of hemoglobin molecules that bind oxygen in the lungs and transport it to all the tissues in the body. A cell’s plasma
membrane is usually not permeable to large polar molecules, so to get the required nutrients and molecules into the cell many
transport proteins exist in the cell membrane. Some of these proteins are channels that allow particular molecules to move in and
out of cells. Others act as one-way taxis and require energy to function.

Protection
An antibody protein is made up of two heavy chains and two light chains. The variable region, which differs from one antibody to
the next, allows an antibody to recognize its matching antigen.

6.5.3 [Link]
 Figure : Antibody Proteins. Abagovomab (monoclonal antibody). (CC BY-SA 3.0;
Blake C via Wikipedia)
Earlier we discussed that the strong collagen fibers in skin provide it with structure and support. The skin’s dense network of
collagen fibers also serves as a barricade against harmful substances. The immune system’s attack and destroy functions are
dependent on enzymes and antibodies, which are also proteins. An enzyme called lysozyme is secreted in the saliva and attacks the
walls of bacteria, causing them to rupture. Certain proteins circulating in the blood can be directed to build a molecular knife that
stabs the cellular membranes of foreign invaders. The antibodies secreted by the white blood cells survey the entire circulatory
system looking for harmful bacteria and viruses to surround and destroy. Antibodies also trigger other factors in the immune system
to seek and destroy unwanted intruders.

Antigen-
binding
site

Light
chain
Heavy
chain

Variable region

Constant region
Figure : Antigens. Antibody chains by Fred the Oyster / Public Domain

Wound Healing and Tissue Regeneration

Proteins are involved in all aspects of wound healing, a process that takes place in three phases: inflammatory, proliferative, and
remodeling. For example, if you were sewing and pricked your finger with a needle, your flesh would turn red and become
inflamed. Within a few seconds bleeding would stop. The healing process begins with proteins such as bradykinin, which dilate
blood vessels at the site of injury. An additional protein called fibrin helps to secure platelets that form a clot to stop the bleeding.
Next, in the proliferative phase, cells move in and mend the injured tissue by installing newly made collagen fibers. The collagen
fibers help pull the wound edges together. In the remodeling phase, more collagen is deposited, forming a scar. Scar tissue is only
about 80 percent as functional as normal uninjured tissue. If a diet is insufficient in protein, the process of wound healing is
markedly slowed.
While wound healing takes place only after an injury is sustained, a different process called tissue regeneration is ongoing in the
body. The main difference between wound healing and tissue regeneration is in the process of regenerating an exact structural and
functional copy of the lost tissue. Thus, old, dying tissue is not replaced with scar tissue but with brand new, fully functional tissue.
Some cells (such as skin, hair, nails, and intestinal cells) have a very high rate of regeneration, while others, (such as heart-muscle
cells and nerve cells) do not regenerate at any appreciable levels. Tissue regeneration is the creation of new cells (cell division),
which requires many different proteins including enzymes that synthesize RNA and proteins, transport proteins, hormones, and
collagen. In a hair follicle, cells divide and a hair grows in length. Hair growth averages 1 centimeter per month and fingernails

6.5.4 [Link]
about 1 centimeter every one hundred days. The cells lining the intestine regenerate every three to five days. Protein-inadequate
diets impair tissue regeneration, causing many health problems including impairment of nutrient digestion and absorption and,
most visibly, hair and nail growth.

Energy Production
Some of the amino acids in proteins can be disassembled and used to make energy (Figure 6.14). Only about 10 percent of dietary
proteins are catabolized each day to make cellular energy. The liver is able to break down amino acids to the carbon skeleton,
which can then be fed into the citric acid cycle. This is similar to the way that glucose is used to make ATP. If a person’s diet does
not contain enough carbohydrates and fats their body will use more amino acids to make energy, which compromises the synthesis
of new proteins and destroys muscle proteins. Alternatively, if a person’s diet contains more protein than the body needs, the extra
amino acids will be broken down and transformed into fat.

Figure : Amino Acids Used for Energy.

Image by Allison Calabrese / CC BY 4.0
An antibody protein is made up of two heavy chains and two light chains. The variable region, which differs from one antibody to
the next, allows an antibody to recognize its matching antigen.

This page titled 6.5: Protein’s Functions in the Body is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by
Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
6.5: Protein’s Functions in the Body by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0.
Original source: [Link]

6.5.5 [Link]
6.6: Diseases Involving Proteins
As you may recall, moderation refers to having the proper amount of a nutrient—having neither too little nor too much. A healthy
diet incorporates all nutrients in moderation. Low protein intake has several health consequences, and a severe lack of protein in the
diet eventually causes death. Although severe protein deficiency is a rare occurrence in children and adults in the United States, it is
estimated that more than half of the elderly in nursing homes are protein-deficient. The Acceptable Macronutrient Distribution
Range (AMDR) for protein for adults is between 10 and 35 percent of kilocalories, which is a fairly wide range. The percent of
protein in the diet that is associated with malnutrition and its health consequences is less than 10 percent, but this is often
accompanied by deficiencies in calories and other micronutrients. In this section we will discuss the health consequences of protein
intake that is either too low to support life’s processes or too high, thereby increasing the risk of chronic disease. In the last section
of this chapter, we will discuss in more detail the personal choices you can make to optimize your health by consuming the right
amount of high-quality protein.

Health Consequences of Protein Deficiency

Although severe protein deficiency is rare in the developed world, it is a leading cause of death in children in many poor,
underdeveloped countries. There are two main syndromes associated with protein deficiencies: Kwashiorkor and Marasmus.
Kwashiorkor affects millions of children worldwide. When it was first described in 1935, more than 90 percent of children with
Kwashiorkor died. Although the associated mortality is slightly lower now, most children still die after the initiation of treatment.
The name Kwashiorkor comes from a language in Ghana and means, “rejected one.” The syndrome was named because it occurred
most commonly in children who had recently been weaned from the breast, usually because another child had just been born.
Subsequently the child was fed watery porridge made from low-protein grains, which accounts for the low protein intake.
Kwashiorkor is characterized by swelling (edema) of the feet and abdomen, poor skin health, growth retardation, low muscle mass,
and liver malfunction. Recall that one of protein’s functional roles in the body is fluid balance. Diets extremely low in protein do
not provide enough amino acids for the synthesis of albumin. One of the functions of albumin is to hold water in the blood vessels,
so having lower concentrations of blood albumin results in water moving out of the blood vessels and into tissues, causing
swelling. The primary symptoms of Kwashiorkor include not only swelling, but also diarrhea, fatigue, peeling skin, and irritability.
Severe protein deficiency in addition to other micronutrient deficiencies, such as folate (vitamin B9), iodine, iron, and vitamin C all
contribute to the many health manifestations of this syndrome.

Figure : A Young Boy With Kwashiorkor. Source: Photo courtesy of the Centers for
Disease Control and Prevention (CDC).
Kwashiorkor is a disease brought on by a severe dietary protein deficiency. Symptoms include edema of legs and feet, light-
colored, thinning hair, anemia, a pot-belly, and shiny skin.

6.6.1 [Link]
Children and adults with marasmus neither have enough protein in their diets nor do they take in enough calories. Marasmus affects
mostly children below the age of one in poor countries. Body weights of children with Marasmus may be up to 80 percent less than
that of a normal child of the same age. Marasmus is a Greek word, meaning “starvation.” The syndrome affects more than fifty
million children under age five worldwide. It is characterized by an extreme emaciated appearance, poor skin health, and growth
retardation. The symptoms are acute fatigue, hunger, and diarrhea.

Figure : Children With Marasmus. Japanese nurse with dependent

children having typical appearance of malnutrition, New Bilibid Prison, September-October 1945 by Unknown / Public Domain
Kwashiorkor and marasmus often coexist as a combined syndrome termed marasmic kwashiorkor. Children with the combined
syndrome have variable amounts of edema and the characterizations and symptoms of marasmus. Although organ system function
is compromised by undernutrition, the ultimate cause of death is usually infection. Undernutrition is intricately linked with
suppression of the immune system at multiple levels, so undernourished children commonly die from severe diarrhea and/or
pneumonia resulting from bacterial or viral infection. The United Nations Children’s Fund (UNICEF), the most prominent agency
with the mission of changing the world to improve children’s lives, reports that undernutrition causes at least one-third of deaths of
young children. As of 2008, the prevalence of children under age five who were underweight was 26 percent. The percentage of
underweight children has declined less than 5 percent in the last eighteen years despite the Millennium Development Goal of
halving the proportion of people who suffer from hunger by the year 2015.

6.6.2 [Link]
 Figure : Causes Of Death For Children Under The Age Of Five,
Worldwide. Figure 6.17 Causes Of Death For Children Under The Age Of Five, Worldwide

Health Consequences of Too Much Protein in the Diet

An explicit definition of a high-protein diet has not yet been developed by the Food and Nutrition Board of the Institute of
Medicine (IOM), but typically diets high in protein are considered as those that derive more than 30 percent of calories from
protein. Many people follow high-protein diets because marketers tout protein’s ability to stimulate weight loss. It is true that
following high-protein diets increases weight loss in some people. However the number of individuals that remain on this type of
diet is low and many people who try the diet and stop regain the weight they had lost. Additionally, there is a scientific hypothesis
that there may be health consequences of remaining on high-protein diets for the long-term, but clinical trials are ongoing or
scheduled to examine this hypothesis further. As the high-protein diet trend arose so did the intensely debated issue of whether
there are any health consequences of eating too much protein. Observational studies conducted in the general population suggest
diets high in animal protein, specifically those in which the primary protein source is red meat, are linked to a higher risk for
kidney stones, kidney disease, liver malfunction, colorectal cancer, and osteoporosis. However, diets that include lots of red meat
are also high in saturated fat and cholesterol and sometimes linked to unhealthy lifestyles, so it is difficult to conclude that the high
protein content is the culprit.
High protein diets appear to only increase the progression of kidney disease and liver malfunction in people who already have
kidney or liver malfunction, and not to cause these problems. However, the prevalence of kidney disorders is relatively high and
underdiagnosed. In regard to colon cancer, an assessment of more than ten studies performed around the world published in the
June 2011 issue of PLoS purports that a high intake of red meat and processed meat is associated with a significant increase in
colon cancer risk.[1]Although there are a few ideas, the exact mechanism of how proteins, specifically those in red and processed
meats, causes colon cancer is not known and requires further study.
Some scientists hypothesize that high-protein diets may accelerate bone-tissue loss because under some conditions the acids in
protein block absorption of calcium in the gut, and, once in the blood, amino acids promote calcium loss from bone; however even
these effects have not been consistently observed in scientific studies. Results from the Nurses’ Health Study suggest that women
who eat more than 95 grams of protein each day have a 20 percent higher risk for wrist fracture.[2][3]
Other studies have not produced consistent results. The scientific data on high protein diets and increased risk for osteoporosis
remains highly controversial and more research is needed to come to any conclusions about the association between the two.[4]
High-protein diets can restrict other essential nutrients. The American Heart Association (AHA) states that “High-protein diets are
not recommended because they restrict healthful foods that provide essential nutrients and do not provide the variety of foods
needed to adequately meet nutritional needs. Individuals who follow these diets are therefore at risk for compromised vitamin and
mineral intake, as well as potential cardiac, renal, bone, and liver abnormalities overall.”[5]

6.6.3 [Link]
As with any nutrient, protein must be eaten in proper amounts. Moderation and variety are key strategies to achieving a healthy diet
and need to be considered when optimizing protein intake. While the scientific community continues its debate about the
particulars regarding the health consequences of too much protein in the diet, you may be wondering just how much protein you
should consume to be healthy. Read on to find out more about calculating your dietary protein recommendations, dietary protein
sources, and personal choices about protein.

Resources
1. Chan DS, Lau R, et al. (2011). Red and Processed Meat and Colorectal Cancer Incidence: Meta-Analysis of Prospective
Studies. PLoS One, 6(6), e20456. [Link] Accessed September 30, 2017. ↵
2. Protein: The Bottom Line. Harvard School of Public [Link] Nutrition Source. [Link]/nutritionsource/what-
should-you-eat/protein/.Published 2012. Accessed September 28, 2017. ↵
3. Barzel US, Massey LK. (1998). Excess Dietary Protein Can Adversely Affect Bone. Journal of Nutrition, 128(6), 1051–53.
[Link]/content/128/6/[Link]. Accessed September 28, 2017. ↵
4. St. Jeor ST, et al.(2001). Dietary Protein and Weight Reduction: A Statement for Healthcare Professionals from the Nutrition
Committee of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association. Circulation, 104,
1869–74. [Link]/cgi/pmidlookup?view=long&pmid=11591629. Accessed September 28, 2017. ↵
5. St. Jeor ST, et al. (2001). Dietary Protein and Weight Reduction: A Statement for Healthcare Professionals from the Nutrition
Committee of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association. Circulation, 104,
1869–74. [Link]/cgi/pmidlookup?view=long&pmid=11591629. Accessed September 28, 2017. ↵

This page titled 6.6: Diseases Involving Proteins is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by
Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
6.6: Diseases Involving Proteins by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0.
Original source: [Link]

6.6.4 [Link]
6.7: Proteins in a Nutshell
Proteins are long chains of amino acids folded into precise structures that determine their functions, which are in the tens of
thousands. They are the primary construction materials of the body serving as building blocks for bone, skin, hair, muscle,
hormones, and antibodies. Without them we cannot breakdown or build macromolecules, grow, or heal from a wound. Too little
protein impairs bodily functions and too much can lead to chronic disease. Eat proteins in moderation, at least 10 percent of the
calories you take in and not more than 35 percent. Proteins are in a variety of foods. More complete sources are in animal-based
foods, but choose those low in saturated fat and cholesterol. Some plant-based foods are also complete protein sources and don’t
add much to your saturated fat or cholesterol intake. Incomplete protein sources can easily be combined in the daily diet and
provide all of the essential amino acids at adequate levels. Growing children and the elderly need to ensure they get enough protein
in their diet to help build and maintain muscle strength. Even if you’re a hardcore athlete, get your proteins from nutrient-dense
foods as you need more than just protein to power up for an event. Nuts are one nutrient-dense food with a whole lot of protein.
One ounce of pistachios, which is about fifty nuts, has the same amount of protein as an egg and contains a lot of vitamins,
minerals, healthy polyunsaturated fats, and antioxidants. Moreover, the FDA says that eating one ounce of nuts per day can lower
your risk for heart disease. Can you be a hardcore athlete and a vegetarian?

Figure : Image by Braden Collum on

[Link] / CC0
The analysis of vegetarian diets by the Dietary Guidelines Advisory Committee (DGAC) did not find professional athletes were
inadequate in any nutrients, but did state that people who obtain proteins solely from plants should make sure they consume foods
with vitamin B12, vitamin D, calcium, omega-3 fatty acids, and choline. Iron and zinc may also be of concern especially for female
athletes. Being a vegetarian athlete requires that you pay more attention to what you eat, however this is also a true statement for all
athletes. For an exhaustive list that provides the protein, calcium, cholesterol, fat, and fiber content, as well as the number of
calories, of numerous foods, go to the website, [Link]

 Everyday Connection

Getting All the Nutrients You Need—The Plant-Based Way

Below are five ways to assure you are getting all the nutrients needed on a plant-based diet;
Get your protein from foods such as soybeans, tofu, tempeh, lentils, and beans, beans, and more beans. Many of these foods
are high in zinc too.
Eat foods fortified with vitamins B12 and D and calcium. Some examples are soy milk and fortified cereals.
Get enough iron in your diet by eating kidney beans, lentils, whole-grain cereals, and leafy green vegetables.
To increase iron absorption, eat foods with vitamin C at the same time.

6.7.1 [Link]
 Don’t forget that carbohydrates and fats are required in your diet too, especially if you are training. Eat whole-grain breads,
cereals, and pastas. For fats, eat an avocado, add some olive oil to a salad or stir-fry, or spread some peanut or cashew
butter on a bran muffin.

This page titled 6.7: Proteins in a Nutshell is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer
Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts
platform.
6.7: Proteins in a Nutshell by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original
source: [Link]

6.7.2 [Link]
6.8: Proteins, Diet, and Personal Choices
We have discussed what proteins are, how they are made, how they are digested and absorbed, the many functions of proteins in the
body, and the consequences of having too little or too much protein in the diet. This section will provide you with information on
how to determine the recommended amount of protein for you, and your many choices in designing an optimal diet with high-
quality protein sources.

How Much Protein Does a Person Need in Their Diet?

The recommendations set by the IOM for the Recommended Daily Allowance (RDA) and AMDR for protein for different age
groups are listed in Table . A Tolerable Upper Intake Limit for protein has not been set, but it is recommended that you do not
exceed the upper end of the AMDR.
Table : Dietary Reference Intakes for Protein
Age Group RDA (g/day) AMDR (% calories)

Infants (0–6 mo) 9.1* Not determined

Infants (7–12 mo) 11.0 Not determined

Children (1–3) 13.0 5–20

Children (4–8) 19.0 10–30

Children (9–13) 34.0 10–30

Males (14–18) 52.0 10–30

Females (14–18) 46.0 10–30

Adult Males (19+) 56.0 10–35

Adult Females (19+) 46.0 10–35

* Denotes Adequate Intake

Source: Dietary Reference Intakes: Macronutrients. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids,
Cholesterol, Protein, and Amino Acids. Institute of Medicine. September 5, 2002. Accessed September 28, 2017.
Protein Input = Protein Used by the Body + Protein Excreted
The appropriate amount of protein in a person’s diet is that which maintains a balance between what is taken in and what is used.
The RDAs for protein were determined by assessing nitrogen balance. Nitrogen is one of the four basic elements contained in all
amino acids. When proteins are broken down and amino acids are catabolized, nitrogen is released. Remember that when the liver
breaks down amino acids, it produces ammonia, which is rapidly converted to nontoxic, nitrogen-containing urea, which is then
transported to the kidneys for excretion. Most nitrogen is lost as urea in the urine, but urea is also excreted in the feces. Proteins are
also lost in sweat and as hair and nails grow. The RDA, therefore, is the amount of protein a person should consume in their diet to
balance the amount of protein used up and lost from the body. For healthy adults, this amount of protein was determined to be 0.8
grams of protein per kilogram of body weight. You can calculate your exact recommended protein intake per day based on your
weight by using the following equation:
(Weight in lbs. ÷ 2.2 lb/kg) × 0.8 g/kg
Note that if a person is overweight, the amount of dietary protein recommended can be overestimated.
The IOM used data from multiple studies that determined nitrogen balance in people of different age groups to calculate the RDA
for protein. A person is said to be in nitrogen balance when the nitrogen input equals the amount of nitrogen used and excreted. A
person is in negative nitrogen balance when the amount of excreted nitrogen is greater than that consumed, meaning that the body
is breaking down more protein to meet its demands. This state of imbalance can occur in people who have certain diseases, such as

6.8.1 [Link]
cancer or muscular dystrophy. Someone who has a low-protein diet may also be in negative nitrogen balance as they are taking in
less protein than what they actually need. Positive nitrogen balance occurs when a person excretes less nitrogen than what is taken
in by the diet, such as during child growth or pregnancy. At these times the body requires more protein to build new tissues, so
more of what gets consumed gets used up and less nitrogen is excreted. A person healing from a severe wound may also be in
positive nitrogen balance because protein is being used up to repair tissues.

Dietary Sources of Protein

The protein food group consists of foods made from meat, seafood, poultry, eggs, soy, dry beans, peas, and seeds. According to the
Harvard School of Public Health, “animal protein and vegetable protein probably have the same effects on health. It’s the protein
package that’s likely to make a difference.”[1]
Simply put, different protein sources differ in their additional components, so it is necessary to pay attention to the whole nutrient
“package.” Protein-rich animal-based foods commonly have high amounts of B vitamins, vitamin E, iron, magnesium, and zinc.
Seafood often contains healthy fats, and plant sources of protein contain a high amount of fiber. Some animal-based protein-rich
foods have an unhealthy amount of saturated fat and cholesterol. When choosing your dietary sources of protein, take note of the
other nutrients and also the non-nutrients, such as cholesterol, dyes, and preservatives, in order to make good selections that will
benefit your health. For instance, a hamburger patty made from 80 percent lean meat contains 22 grams of protein, 5.7 grams of
saturated fat, and 77 milligrams of cholesterol. A burger made from 95 percent lean meat also contains 22 grams of protein, but has
2.3 grams of saturated fat and 60 milligrams of cholesterol. A cup of boiled soybeans contains 29 grams of protein, 2.2 grams of
saturated fat, and no cholesterol. For more comparisons of protein-rich foods, see Table . To find out the complete nutrient
package of different foods, visit the US Department of Agriculture (USDA) Food Composition Databases.
Table : Sources of Dietary Protein

6.8.2 [Link]
 Food Protein Content (g) Saturated Fat (g) Cholesterol (mg) Calories

Hamburger patty 3 oz.

22.0 5.7 77 230
(80% lean)

Hamburger patty 3 oz.

22.0 2.3 60 139
(95% lean)

Top sirloin 3 oz. 25.8 2.0 76 158

Beef chuck 3 oz. (lean,

22.2 1.8 51 135
trimmed)

Pork loin 3 oz. 24.3 3.0 69 178

Pork ribs (country style,

56.4 22.2 222 790
1 piece)

Chicken breast (roasted,

43.4 1.4 119 231
1 c.)

Chicken thigh (roasted, 1

13.5 1.6 49 109
thigh)

Chicken leg (roasted, 1

29.6 4.2 105 264
leg)

Salmon 3 oz. 18.8 2.1 54 175

Tilapia 3 oz. 22.2 0.8 48 109

Halibut 3 oz. 22.7 0.4 35 119

Shrimp 3 oz. 17.8 0.2 166 84

Shrimp (breaded, fried,

18.9 5.4 200 454
6–8 pcs.)

Tuna 3 oz. (canned) 21.7 0.2 26 99

Soybeans 1 c. (boiled) 29.0 2.2 0 298

Lentils 1 c. (boiled) 17.9 0.1 0 226

Kidney beans 1 c.
13.5 0.2 0 215
(canned)

Sunflower seeds 1 c. 9.6 2.0 0 269

The USDA provides some tips for choosing your dietary protein sources. Their motto is, “Go Lean with Protein”. The overall
suggestion is to eat a variety of protein-rich foods to benefit health. The USDA recommends lean meats, such as round steaks, top
sirloin, extra lean ground beef, pork loin, and skinless chicken. Additionally, a person should consume 8 ounces of cooked seafood
every week (typically as two 4-ounce servings) to assure they are getting the healthy omega-3 fatty acids that have been linked to a
lower risk for heart disease. Another tip is choosing to eat dry beans, peas, or soy products as a main dish. Some of the menu
choices include chili with kidney and pinto beans, hummus on pita bread, and black bean enchiladas. You could also enjoy nuts in a
variety of ways. You can put them on a salad, in a stir-fry, or use them as a topping for steamed vegetables in place of meat or
cheese. If you do not eat meat, the USDA has much more information on how to get all the protein you need from a plant-based
diet. When choosing the best protein-rich foods to eat, pay attention to the whole nutrient package and remember to select from a
variety of protein sources to get all the other essential micronutrients.

6.8.3 [Link]
Protein Quality
While protein is contained in a wide variety of foods, it differs in quality. High-quality protein contains all the essential amino acids
in the proportions needed by the human body. The amino acid profile of different foods is therefore one component of protein
quality. Foods that contain some of the essential amino acids are called incomplete protein sources, while those that contain all nine
essential amino acids are called complete protein sources, or high-quality protein sources. Foods that are complete protein sources
include animal foods such as milk, cheese, eggs, fish, poultry, and meat, and a few plant foods, such as soy and quinoa. The only
animal-based protein that is not complete is gelatin, which is made of the protein, collagen.

Figure : Complete and Incomplete Protein Sources. Protein-

rich Foods by Smastronardo / CC BY-SA 4.0
Examples of complete protein sources include soy, dairy products, meat, and seafood. Examples of incomplete protein sources
include legumes and corn.
Most plant-based foods are deficient in at least one essential amino acid and therefore are incomplete protein sources. For example,
grains are usually deficient in the amino acid lysine, and legumes are deficient in methionine or tryptophan. Because grains and
legumes are not deficient in the same amino acids they can complement each other in a diet. Incomplete protein foods are called
complementary foods because when consumed in tandem they contain all nine essential amino acids at adequate levels. Some
examples of complementary protein foods are given in Table . Complementary protein sources do not have to be consumed at
the same time—as long as they are consumed within the same day, you will meet your protein needs.
Table : Complementing Protein Sources the Vegan Way

Foods Lacking Amino Acids Complementary Food Complementary Menu

Legumes Methionine, tryptophan Grains, nuts, and seeds Hummus and whole-wheat pita

Cornbread and kidney bean

Grains Lysine, isoleucine, threonine Legumes
chili

Nuts and seeds Lysine, isoleucine Legumes Stir-fried tofu with cashews

The second component of protein quality is digestibility, as not all protein sources are equally digested. In general, animal-based
proteins are completely broken down during the process of digestion, whereas plant-based proteins are not. This is because some
proteins are contained in the plant’s fibrous cell walls and these pass through the digestive tract unabsorbed by the body.

Protein Digestibility Corrected Amino Acid Score (PDCAAS)

The PDCAAS is a method adopted by the US Food and Drug Administration (FDA) to determine a food’s protein quality. It is
calculated using a formula that incorporates the total amount of amino acids in the food and the amount of protein in the food that
is actually digested by humans. The food’s protein quality is then ranked against the foods highest in protein quality. Milk protein,
egg whites, whey, and soy all have a ranking of one, the highest ranking. Other foods’ ranks are listed in Table .

6.8.4 [Link]
 Table : PDCAAS of Various Foods

Food PDCAAS*

Milk protein 1.00

Egg white 1.00

Whey 1.00

Soy protein 1.00

Beef 0.92

Soybeans 0.91

Chickpeas 0.78

Fruits 0.76

Vegetables 0.73

Whole wheat 0.42

*1 is the highest rank, 0 is the lowest

Protein Needs: Special Considerations

Some groups may need to examine how to meet their protein needs more closely than others. We will take a closer look at the
special protein considerations for vegetarians, the elderly, and athletes.

Vegetarians and Vegans

People who follow variations of the vegetarian diet and consume eggs and/or dairy products can meet their protein requirements by
consuming adequate amounts of these foods. Vegetarians and vegans can also attain their recommended protein intakes if they give
a little more attention to high-quality plant-based protein sources. However, when following a vegetarian diet, the amino acid lysine
can be challenging to acquire. Grains, nuts, and seeds are lysine-poor foods, but tofu, soy, quinoa, and pistachios are all good
sources of lysine. Following a vegetarian diet and getting the recommended protein intake is also made a little more difficult
because the digestibility of plant-based protein sources is lower than the digestibility of animal-based protein.
To begin planning a more plant-based diet, start by finding out which types of food you want to eat and in what amounts you
should eat them to ensure that you get the protein you need. The Dietary Guidelines Advisory Committee (DGAC) has analyzed
how three different, plant-based dietary patterns can meet the recommended dietary guidelines for all nutrients.[2]
The diets are defined in the following manner:
Plant-based. Fifty percent of protein is obtained from plant foods.
Lacto-ovo vegetarian. All animal products except eggs and dairy are eliminated.
Vegan. All animal products are eliminated.
These diets are analyzed and compared to the more common dietary pattern of Americans, which is referred to as the USDA Base
Diet. Table 6.6 Components in the USDA Base Diet, and Three Vegetarian Variations” and Table can be used to help
determine what percentage of certain foods to eat when following a different dietary pattern. The percentages of foods in the
different groups are the proportions consumed by the population, so that, on average, Americans obtain 44.6 percent of their foods
in the meat and beans group from meats. If you choose to follow a lacto-ovo vegetarian diet, the meats, poultry, and fish can be
replaced by consuming a higher percentage of soy products, nuts, seeds, dry beans, and peas. As an aside, the DGAC notes that
these dietary patterns may not exactly align with the typical diet patterns of people in the United States. However, they do say that
they can be adapted as a guide to develop a more plant-based diet that does not significantly affect nutrient adequacy.
Table : Percentage of “Meat and Beans Group” Components in the USDA Base Diet, and Three Vegetarian Variations

6.8.5 [Link]
 Lacto-Ovo Vegetarian
Food Category Base USDA (%) Plant-Based (%) Vegan (%)
(%)

Meats 44.6 10.5 0 0

Poultry 27.9 8.0 0 0

Fish (high omega-3) 2.2 3.0 0 0

Fish (low omega-3) 7.1 10.0 0 0

Eggs 7.9 7.6 10.0 0

Soy products 0.9 15.0 30.0 25.0

Nuts and seeds 9.4 20.9 35.0 40.0

Dry beans and peas n/a* 25.0 25.0 35.0

Total 100.0 100.0 100.0 100.0

*The dry beans and peas are in the vegetable food group of the base diet. Source: Vegetarian Food Patterns: Food Pattern Modeling
Analysis. US Department of Agriculture. Appendix E-3.3. [Link]/Publication...[Link]. Accessed September
28, 2017.
Table : Proportions of Milk Products and Calcium-Fortified Soy Products in the Base USDA Patterns and Three Vegetarian Variations

Food Category Base USDA (%) Plant-based (%) Lacto-ovo vegetarian (%) Vegan (%)

Fluid milk 54.6 54.6 54.6 0

Yogurt 1.6 1.6 1.6 0

Cheese 42.7 42.7 42.7 0

Soy milk (w/ calcium) 1.1 1.1 1.1 67.0

Rice milk (w/ calcium) 0 0 0 16.0

Tofu (w/ calcium) 0 0 0 15.0

Soy yogurt 0 0 0 2.0

Total 100.0 100.0 100.0 100.0

Source: Vegetarian Food Patterns: Food Pattern Modeling Analysis. US Department of Agriculture. Appendix E-3.3.
[Link]/Publication...[Link]. Accessed September 28, 2017.
From these analyses the DGAC concluded that the plant-based, lacto-ovo vegetarian, and vegan diets do not significantly affect
nutrient adequacy. Additionally, the DGAC states that people who choose to obtain proteins solely from plants should include foods
fortified with vitamins B12, D, and calcium. Other nutrients of concern may be omega-3 fatty acids and choline.

The Elderly
As we age, muscle mass gradually declines. This is a process referred to as sarcopenia. A person is sarcopenic when their amount
of muscle tissue is significantly lower than the average value for a healthy person of the same age. A significantly lower muscle
mass is associated with weakness, movement disorders, and a generally poor quality of life. It is estimated that about half the US
population of men and women above the age of eighty are sarcopenic. A review published in the September 2010 issue of Clinical
Intervention in Aging demonstrates that higher intakes (1.2 to 1.5 grams per kilogram of weight per day) of high-quality protein
may prevent aging adults from becoming sarcopenic.[3]

6.8.6 [Link]
Currently, the RDA for protein for elderly persons is the same as that for the rest of the adult population, but several clinical trials
are ongoing and are focused on determining the amount of protein in the diet that prevents the significant loss of muscle mass
specifically in older adults.

Athletes
Muscle tissue is rich in protein composition and has a very high turnover rate. During exercise, especially when it is performed for
longer than two to three hours, muscle tissue is broken down and some of the amino acids are catabolized to fuel muscle
contraction. To avert excessive borrowing of amino acids from muscle tissue to synthesize energy during prolonged exercise,
protein needs to be obtained from the diet. Intense exercise, such as strength training, stresses muscle tissue so that afterward, the
body adapts by building bigger, stronger, and healthier muscle tissue. The body requires protein post-exercise to accomplish this.
The IOM does not set different RDAs for protein intakes for athletes, but the AND, the American College of Sports Medicine, and
Dietitians of Canada have the following position statements[4]:
Nitrogen balance studies suggest that dietary protein intake necessary to support nitrogen balance in endurance athletes ranges from
1.2 to 1.4 grams per kilogram of body weight per day.
Recommended protein intakes for strength-trained athletes range from approximately 1.2 to 1.7 grams per kilogram of weight per
day.
An endurance athlete who weighs 170 pounds should take in 93 to 108 grams of protein per day (170 ÷ 2.2 × 1.2 and 170 ÷ 2.2 ×
1.4). On a 3,000-kilocalorie diet, that amount is between 12 and 14 percent of total kilocalories and within the AMDR. There is
general scientific agreement that endurance and strength athletes should consume protein from high-quality sources, such as dairy,
eggs, lean meats, or soy; however eating an excessive amount of protein at one time does not further stimulate muscle-protein
synthesis. Nutrition experts also recommend that athletes consume some protein within one hour after exercise to enhance muscle
tissue repair during the recovery phase, but some carbohydrates and water should be consumed as well. The recommended ratio
from nutrition experts for exercise-recovery foods is 4 grams of carbohydrates to 1 gram of protein.
Table : Snacks for Exercise Recovery

Foods Protein (g) Carbohydrates (g) Calories

Whole grain cereal with nonfat

14 53 260
milk

Medium banana with nonfat

10 39 191
milk

Power bar 10 43 250

In response to hard training, a person’s body also adapts by becoming more efficient in metabolizing nutrient fuels both for energy
production and building macromolecules. However, this raises another question: if athletes are more efficient at using protein, is it
necessary to take in more protein from dietary sources than the average person? There are two scientific schools of thought on this
matter. One side believes athletes need more protein and the other thinks the protein requirements of athletes are the same as for
nonathletes. There is scientific evidence to support both sides of this debate. The consensus of both sides is that few people exercise
at the intensity that makes this debate relevant. It is good to remember that the increased protein intake recommended by the AND,
American College of Sports Medicine, and Dietitians of Canada still lies within the AMDR for protein.

Protein Supplements
Protein supplements include powders made from compounds such as whey, soy or amino acids that either come as a powder or in
capsules. We have noted that the protein requirements for most people, even those that are active, is not high. Is taking protein
supplements ever justified, then? Neither protein nor amino acid supplements have been scientifically proven to improve exercise
performance or increase strength. In addition, the average American already consumes more protein than is required. Despite these
facts, many highly physically active individuals use protein or amino acid supplements. According to the AND, American College
of Sports Medicine, and Dietitians of Canada, “the current evidence indicates that protein and amino acid supplements are no more
or no less effective than food when energy is adequate for gaining lean body mass.”[5]

6.8.7 [Link]
Branched-chain amino acids, such as leucine, are often touted as a way to build muscle tissue and enhance athletic performance.
Despite these marketing claims, a review in the June 2005 issue of The Journal of Nutrition shows that most studies that evaluated
a variety of exercise types failed to show any performance-enhancing effects of taking branched-chain amino acids.[6]
Moreover, the author of this review claims that high-quality protein foods are a better and cheaper source for branched-chain amino
acids and says that a chicken breast (100 grams) contains the equivalent of seven times the amount of branched-chain amino acids
as one supplement tablet. This means if you are interested in enhancing exercise performance or building muscle, you do not need
to support the $20 billion supplement industry.
Although the evidence for protein and amino acid supplements impacting athletic performance is lacking, there is some scientific
evidence that supports consuming high-quality dairy proteins, such as casein and whey, and soy proteins positively influences
muscle recovery in response to hard training. If you choose to buy a bucket of whey protein, use it to make a protein shake after an
intense workout and do not add more than what is required to obtain 20 to 25 grams of protein. As always, choosing high-quality
protein foods will help you build muscle and not empty your wallet as much as buying supplements. Moreover, relying on
supplements for extra protein instead of food will not provide you with any of the other essential nutrients. The bottom line is that
whether you are an endurance athlete or strength athlete, or just someone who takes Zumba classes, there is very little need to put
your money into commercially sold protein and amino acid supplements. The evidence to show that they are superior to regular
food in enhancing exercise performance is not sufficient.
What about the numerous protein shakes and protein bars on the market? Are they a good source of dietary protein? Do they help
you build muscle or lose weight as marketers claim? These are not such a bad idea for an endurance or strength athlete who has
little time to fix a nutritious exercise-recovery snack. However, before you ingest any supplement, do your homework. Read the
label, be selective, and don’t use them to replace meals, but rather as exercise-recovery snacks now and then. Some protein bars
have a high amount of carbohydrates from added sugars and are not actually the best source for protein, especially if you are not an
athlete. Protein bars are nutritionally designed to restore carbohydrates and protein after endurance or strength training; therefore
they are not good meal replacements. If you want a low-cost alternative after an intense workout, make yourself a peanut butter
sandwich on whole-grain bread and add some sliced banana for less than fifty cents.
Supermarket and health-food store shelves offer an extraordinary number of high-protein shake mixes. While the carbohydrate
count is lower now in some of these products than a few years ago, they still contain added fats and sugars. They also cost, on
average, more than two dollars per can. If you want more nutritional bang for your buck, make your own shakes from whole foods.
Use the AMDRs for macronutrients as a guide to fill up the blender. Your homemade shake can now replace some of the whole
foods on your breakfast, lunch, or dinner plate. Unless you are an endurance or strength athlete and consume commercially sold
protein bars and shakes only postexercise, these products are not a good dietary source of protein.

Resources
1. Protein: The Bottom Line. Harvard School of Public Health. The Nutrition Source.
[Link] Published 2012. Accessed September 30, 2017. ↵
2. Jacobs DR, et al. (2009). Food, Plant Food, and Vegetarian Diets in the US Dietary Guidelines: Conclusions of an Expert Panel.
American Journal of Clinical Nutrition, 89(5). [Link]/content/89/5/[Link]. ↵
3. Waters DL, et al. (2010). Advantages of Dietary, Exercise-Related, and Therapeutic Interventions to Prevent and Treat
Sarcopenia in Adult Patients: An Update. Clinical Interventions in Aging, 5, 259–70.
[Link] Accessed September 28, 2017. ↵
4. American College of Sports Medicine, Academy of Nutrition and Dietetics, and Dietitians of Canada. (2009). Joint Position
Statement: Nutrition and Athletic Performance. Medicine & Science in Sports & Exercise, 41(3), 709-31.
[Link]/acsm-msse/fulltext/2009/03000/Nutrition_and_Athletic_Performance.[Link]. Accessed September 28, 2017.
↵
5. American College of Sports Medicine, Academy of Nutrition and Dietetics, and Dietitians of Canada. (2009). Joint Position
Statement: Nutrition and Athletic Performance. Medicine & Science in Sports & Exercise, 41(3), 709-31.
[Link]/acsm-msse/fulltext/2009/03000/Nutrition_and_Athletic_Performance.[Link]. Accessed September 28, 2017.
↵

6.8.8 [Link]
 6. Gleeson, M. (2005). Interrelationship between Physical Activity and Branched-Chain Amino Acids. Journal of Nutrition,
135(6), 1591S–5S. [Link]/content/135/6/[Link]. Accessed October 1, 2017. ↵

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by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
6.8: Proteins, Diet, and Personal Choices by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-
SA 4.0. Original source: [Link]

6.8.9 [Link]
 CHAPTER OVERVIEW

7: Vitamins
Learning Objectives
By the end of this chapter, you will be able to:
Describe the role of vitamins as antioxidants in the body
Describe the functions and sources of antioxidant micronutrients, phytochemicals, and antioxidant minerals
Describe the functions of vitamins in catabolic pathways, anabolic pathways

7.1: Introduction to Vitamins

7.2: Fat-Soluble Vitamins
7.3: Water-Soluble Vitamins
7.4: Antioxidants
7.5: The Body’s Offense
7.6: Phytochemicals

This page titled 7: Vitamins is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper, Marie
Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.

1
7.1: Introduction to Vitamins
Malia paha he iki ‘unu, pa‘a ka pōhaku nui ‘a‘ole e ka‘a
Perhaps it is the small stone that can keep the big rock from rolling down

Vitamins are obtained from the different types of foods that we consume. If a diet is lacking a certain type of nutrient, a vitamin
deficiency may occur. The traditional diet in Pohnpei (an island in the Federal States of Micronesia) consisted of a diet rich in local
tropical produce such as bananas, papaya, mango, pineapple, coconut as well as seafood. However, due to a shift in dietary patterns
from fresh foods to processed and refined foods the island is suffering from a magnitude of health concerns. A study conducted by
the Department of Health of the Federated States of Micronesia on children aged two to four years old in Pohnpei showed that the
prevalence for vitamin A deficiency among children aged 2-5 was 53 percent[1].
To combat this issue the Island Food Community of Pohnpei has been instrumental in promoting the citizens of Pohnpei to increase
local karat banana consumption. The karat banana is rich in beta-carotene (a source of vitamin A) and increasing consumption
among the locals will decrease the prevalence of vitamin A deficiencies in Pohnpei. For further information on this issue visit the
Island Food Community of Pohnpei’s website at [Link] and watch the video at
[Link]
Vitamins are organic compounds that are traditionally assigned to two groups fat-soluble (hydrophobic) or water-soluble
(hydrophilic). This classification determines where they act in the body. Water-soluble vitamins act in the cytosol of cells or in
extracellular fluids such as blood; fat-soluble vitamins are largely responsible for protecting cell membranes from free radical
damage. The body can synthesize some vitamins, but others must be obtained from the diet.

7.1.1 [Link]
 Figure The Vitamins. Image by
Allison Calabrese / CC BY 4.0
One major difference between fat-soluble vitamins and water-soluble vitamins is the way they are absorbed in the body. Vitamins
are absorbed primarily in the small intestine and their bioavailability is dependent on the food composition of the diet. Fat-soluble
vitamins are absorbed along with dietary fat. Therefore, if a meal is very low in fat, the absorption of the fat-soluble vitamins will
be impaired. Once fat-soluble vitamins have been absorbed in the small intestine, they are packaged and incorporated into
chylomicrons along with other fatty acids and transported in the lymphatic system to the liver. Water-soluble vitamins on the other
hand are absorbed in the small intestine but are transported to the liver through blood vessels.

7.1.2 [Link]
 Figure
“Absorption of Fat-Soluble and Water-Soluble Vitamins. Image by Allison Calabrese / CC BY 4.0
1. Yamamura CM, Sullivan KM. (2004). Risk factors for vitamin A deficiency among preschool aged children in Pohnpei,
Federated States of Micronesia. Journal of Tropical Pediatrics, 50(1),16-9. [Link]
Accessed October 15, 2017. ↵

This page titled 7.1: Introduction to Vitamins is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer
Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts
platform.
9.1: Introduction to Vitamins by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0.
Original source: [Link]

7.1.3 [Link]
7.2: Fat-Soluble Vitamins
Vitamin A Functions and Health Benefits
Vitamin A is a generic term for a group of similar compounds called retinoids. Retinol is the form of vitamin A found in animal-
derived foods, and is converted in the body to the biologically active forms of vitamin A: retinal and retinoic acid (thus retinol is
sometimes referred to as “preformed vitamin A”). About 10 percent of plant-derived carotenoids, including beta-carotene, can be
converted in the body to retinoids and are another source of functional vitamin A. Carotenoids are pigments synthesized by plants
that give them their yellow, orange, and red color. Over six hundred carotenoids have been identified and, with just a few
exceptions, all are found in the plant kingdom. There are two classes of carotenoids—the xanthophylls, which contain oxygen, and
the carotenes, which do not.
In plants, carotenoids absorb light for use in photosynthesis and act as antioxidants. Beta-carotene, alpha-carotene, and beta-
cryptoxanthin are converted to some extent to retinol in the body. The other carotenoids, such as lycopene, are not. Many biological
actions of carotenoids are attributed to their antioxidant activity, but they likely act by other mechanisms, too.
Vitamin A is fat-soluble and is packaged into chylomicrons in small intestine, and transported to the liver. The liver stores and
exports vitamin A as needed; it is released into the blood bound to a retinol-binding protein, which transports it to cells.
Carotenoids are not absorbed as well as vitamin A, but similar to vitamin A, they do require fat in the meal for absorption. In
intestinal cells, carotenoids are packaged into the lipid-containing chylomicrons inside small intestine mucosal cells and then
transported to the liver. In the liver, carotenoids are repackaged into lipoproteins, which transport them to cells.
The retinoids are aptly named as their most notable function is in the retina of the eye where they aid in vision, particularly in
seeing under low-light conditions. This is why night blindness is the most definitive sign of vitamin A deficiency. Vitamin A has
several important functions in the body, including maintaining vision and a healthy immune system. Many of vitamin A’s functions
in the body are similar to the functions of hormones (for example, vitamin A can interact with DNA, causing a change in protein
function). Vitamin A assists in maintaining healthy skin and the linings and coverings of tissues; it also regulates growth and
development. As an antioxidant, vitamin A protects cellular membranes, helps in maintaining glutathione levels, and influences the
amount and activity of enzymes that detoxify free radicals.

Vision
Retinol that is circulating in the blood is taken up by cells in the eye retina, where it is converted to retinal and is used to help the
pigment rhodopsin, which is involved in the eye’s ability to see under low light conditions. A deficiency in vitamin A thus results in
less rhodopsin and a decrease in the detection of low-level light, a condition referred to as night-blindness.

Figure : Bitot Spot caused by vitamin A deficiency. Malnutrition-

Bitot’s Spots/ Bitot’s Spots caused by vitamin A deficiency by CDC / Nutrition Program
Insufficient intake of dietary vitamin A over time can also cause complete vision loss. In fact, vitamin A deficiency is the number
one cause of preventable blindness worldwide. Vitamin A not only supports the vision function of eyes but also maintains the
coverings and linings of the eyes. Vitamin A deficiency can lead to the dysfunction of the linings and coverings of the eye (eg. bitot

7.2.1 [Link]
spots), causing dryness of the eyes, a condition called xerophthalmia. The progression of this condition can cause ulceration of the
cornea and eventually blindness.

Figure : Vitamin A Deficiency World Map. Map by

Wikipedia user Chris55 / CC BY-SA 4.0 Legend: Disability-adjusted life years (DALY) lost from Vitamin A deficiency in 2012 per
million persons.
0-28 31-78 85-85 85-141 144-257 258-376 432-455 558-558 586-883

Immunity
The common occurrence of advanced xerophthalmia in children who died from infectious diseases led scientists to hypothesize that
supplementing vitamin A in the diet for children with xerophthalmia might reduce disease-related mortality. In Asia in the late
1980s, targeted populations of children were administered vitamin A supplements, and the death rates from measles and diarrhea
declined by up to 50 percent. Vitamin A supplementation in these deficient populations did not reduce the number of children who
contracted these diseases, but it did decrease the severity of the diseases so that they were no longer fatal. Soon after the results of
these studies were communicated to the rest of the world, the World Health Organization (WHO) and the United Nations Children’s
Fund (UNICEF) commenced worldwide campaigns against vitamin A deficiency. UNICEF estimates that the distribution of over
half a billion vitamin A capsules prevents 350,000 childhood deaths annually.[1]
In the twenty-first century, science has demonstrated that vitamin A greatly affects the immune system. What we are still lacking
are clinical trials investigating the proper doses of vitamin A required to help ward off infectious disease and how large of an effect
vitamin A supplementation has on populations that are not deficient in this vitamin. This brings up one of our common themes in
this text—micronutrient deficiencies may contribute to the development, progression, and severity of a disease, but this does not
mean that an increased intake of these micronutrients will solely prevent or cure disease. The effect, as usual, is cumulative and
depends on the diet as a whole, among other things.

Growth and Development

Vitamin A acts similarly to some hormones in that it is able to change the amount of proteins in cells by interacting with DNA. This
is the primary way that vitamin A affects growth and development. Vitamin A deficiency in children is linked to growth retardation;
however, vitamin A deficiency is often accompanied by protein malnutrition and iron deficiency, thereby confounding the
investigation of vitamin A’s specific effects on growth and development.
In the fetal stages of life, vitamin A is important for limb, heart, eye, and ear development and in both deficiency and excess,
vitamin A causes birth defects. Furthermore, both males and females require vitamin A in the diet to effectively reproduce.

Cancer
Vitamin A’s role in regulating cell growth and death, especially in tissues that line and cover organs, suggests it may be effective in
treating certain cancers of the lung, neck, and liver. It has been shown in some observational studies that vitamin A-deficient
populations have a higher risk for some cancers. However, vitamin A supplements have actually been found to increase the risk of
lung cancer in people who are at high risk for the disease (i.e., smokers, ex-smokers, workers exposed to asbestos). The Beta-
Carotene and Retinol Efficacy Trial (CARET) involving over eighteen thousand participants who were at high risk for lung cancer
found that people who took supplements containing very high doses of vitamin A (25,000 international units) and beta-carotene had
a 28 percent higher incidence of lung cancer midway through the study, which was consequently stopped.[2]

7.2.2 [Link]
Vitamin A Toxicity
Vitamin A toxicity, or hypervitaminosis A, is rare. Typically it requires you to ingest ten times the RDA of preformed vitamin A in
the form of supplements (it would be hard to consume such high levels from a regular diet) for a substantial amount of time,
although some people may be more susceptible to vitamin A toxicity at lower doses. The signs and symptoms of vitamin A toxicity
include dry, itchy skin, loss of appetite, swelling of the brain, and joint pain. In severe cases, vitamin A toxicity may cause liver
damage and coma.
Vitamin A is essential during pregnancy, but doses above 3,000 micrograms per day (10,000 international units) have been linked to
an increased incidence of birth defects. Pregnant women should check the amount of vitamin A contained in any prenatal or
pregnancy multivitamin she is taking to assure the amount is below the UL.

Dietary Reference Intakes for Vitamin A

There is more than one source of vitamin A in the diet. There is preformed vitamin A, which is abundant in many animal-derived
foods, and there are carotenoids, which are found in high concentrations in vibrantly colored fruits and vegetables and some oils.
Some carotenoids are converted to retinol in the body by intestinal cells and liver cells. However, only minuscule amounts of
certain carotenoids are converted to retinol, meaning fruits and vegetables are not necessarily good sources of vitamin A.
The RDA for vitamin A includes all sources of vitamin A. The RDA for vitamin A is given in mcg of Retinol Activity Equivalent
(RAE) to take into account the many different forms it is available in. The human body converts all dietary sources of vitamin A
into retinol. Therefore, 1 mcg of retinol is equivalent to 12 mcg of beta-carotene, and 24 mcg of alpha-carotene or beta-
cryptoxanthin. For example, 12 micrograms of fruit- or vegetable-based beta-carotene will yield 1 microgram of retinol. Currently
vitamin A listed in food and on supplement labels use international units (IUs). The following conversions are listed below[3]:
1 IU retinol = 0.3 mcg RAE
1 IU beta-carotene from dietary supplements = 0.15 mcg RAE
1 IU beta-carotene from food = 0.05 mcg RAE
1 IU alpha-carotene or beta-cryptoxanthin = 0.025 mcg RAE
The RDA for vitamin A is considered sufficient to support growth and development, reproduction, vision, and immune system
function while maintaining adequate stores (good for four months) in the liver.
Table : Dietary Reference Intakes for Vitamin A

Age Group RDA Males and Females mcg RAE/day UL

Infants (0–6 months) 400* 600

Infants (7–12 months) 500* 600

Children (1–3 years) 300 600

Children (4–8 years) 400 900

Children (9–13 years) 600 1,700

Adolescents (14–18 years) Males: 900 2,800

Adolescents (14–18 years) Females: 700 2,800

Adults (> 19 years) Males: 900 3,000

Adults (> 19 years) Females: 700 3,000

*denotes Adequate Intake

Source: Source: Dietary Supplement Fact Sheet: Vitamin A. National Institutes of Health, Office of Dietary Supplements.
[Link] Updated September 5, 2012. Accessed October 7, 2017.

7.2.3 [Link]
Dietary Sources of Vitamin A and Beta-Carotene
Preformed vitamin A is found only in foods from animals, with the liver being the richest source because that’s where vitamin A is
stored (see Table :). The dietary sources of carotenoids will be given in the following text.
Table : Vitamin A Content of Various Foods
Food Serving Vitamin A (IU) Percent Daily Value

Beef liver 3 oz. 27,185 545

Chicken liver 3 oz. 12,325 245

Milk, skim 1 c. 500 10

Milk, whole 1 c. 249 5

Cheddar cheese 1 oz. 284 6

Source: Dietary Supplement Fact Sheet: Vitamin A. National Institutes of Health, Office of Dietary Supplements.
[Link] Updated September 5, 2012. Accessed October 7, 2017.
In the United States, the most consumed carotenoids are alpha-carotene, beta-carotene, beta-cryptoxanthin, lycopene, lutein, and
zeaxanthin. See Table for the carotenoid content of various foods.
Table : Alpha- and Beta-Carotene Content of Various Foods
Food Serving Beta-carotene (mg) Alpha-carotene (mg)

Pumpkin, canned 1c. 17.00 11.70

Carrot juice 1c. 22.00 10.20

Carrots, cooked 1c. 13.00 5.90

Carrots, raw 1 medium 5.10 2.10

Winter squash, baked 1c. 5.70 1.40

Collards, cooked 1c. 11.60 0.20

Tomato 1 medium 0.55 0.10

Tangerine 1 medium 0.13 0.09

Peas, cooked 1c. 1.20 0.09

Source:2010. USDA National Nutrient Database for Standard Reference, Release 23. US Department of Agriculture, Agricultural
Research Service. [Link] Accessed October 22, 2017.

Vitamin D Functions and Health Benefits

Vitamin D refers to a group of fat-soluble vitamins derived from cholesterol. Vitamins D2 (ergocalciferol) and D3 (calcitriol) are
the only ones known to have biological actions in the human body. The skin synthesizes vitamin D when exposed to sunlight. In
fact, for most people, more than 90 percent of their vitamin D3 comes from the casual exposure to the UVB rays in sunlight.
Anything that reduces your exposure to the sun’s UVB rays decreases the amount of vitamin D3 your skin synthesizes. That would
include long winters, your home’s altitude, whether you are wearing sunscreen, and the color of your skin (including tanned skin).
Do you ever wonder about an increased risk for skin cancer by spending too much time in the sun? Do not fret. Less than thirty
minutes of sun exposure to the arms and legs will increase blood levels of vitamin D3 more than orally taking 10,000 IU (250
micrograms) of vitamin D3.

7.2.4 [Link]
 Figure : The
Functions of Vitamin D. Image by Allison Calabrese / CC BY 4.0

Vitamin D’s Functional Role

Activated vitamin D3 (calcitriol) regulates blood calcium levels in concert with parathyroid hormone. In the absence of an adequate
intake of vitamin D, less than 15 percent of calcium is absorbed from foods or supplements. The effects of calcitriol on calcium
homeostasis are critical for bone health. A deficiency of vitamin D in children causes the bone disease nutritional rickets. Rickets is
very common among children in developing countries and is characterized by soft, weak, deformed bones that are exceptionally
susceptible to fracture. In adults, vitamin D deficiency causes a similar disease called osteomalacia, which is characterized by low
BMD. Osteomalacia has the same symptoms and consequences as osteoporosis and often coexists with osteoporosis. Vitamin D
deficiency is common, especially in the elderly population, dark-skinned populations, and in the many people who live in the
northern latitudes where sunlight exposure is much decreased during the long winter season.

7.2.5 [Link]
 Figure : Rickets in Children. Rickets, stages of development for
children from Wellcome Images / CC BY 4.0

Health Benefits
Observational studies have shown that people with low levels of vitamin D in their blood have lower BMD and an increased
incidence of osteoporosis. In contrast, diets with high intakes of salmon, which contains a large amount of vitamin D, are linked
with better bone health. A review of twelve clinical trials, published in the May 2005 issue of the Journal of the American Medical
Association, concluded that oral vitamin D supplements at doses of 700–800 international units per day, with or without
coadministration of calcium supplements, reduced the incidence of hip fracture by 26 percent and other nonvertebral fractures by
23 percent.[4] A reduction in fracture risk was not observed when people took vitamin D supplements at doses of 400 international
units.
Many other health benefits have been linked to higher intakes of vitamin D, from decreased cardiovascular disease to the
prevention of infection. Furthermore, evidence from laboratory studies conducted in cells, tissues, and animals suggest vitamin D
prevents the growth of certain cancers, blocks inflammatory pathways, reverses atherosclerosis, increases insulin secretion, and
blocks viral and bacterial infection and many other things. Vitamin D deficiency has been linked to an increased risk for
autoimmune diseases. Immune diseases, rheumatoid arthritis, multiple sclerosis, and Type 1 diabetes have been observed in
populations with inadequate vitamin D levels. Additionally, vitamin D deficiency is linked to an increased incidence of
hypertension. Until the results come out from the VITAL study, the bulk of scientific evidence touting other health benefits of
vitamin D is from laboratory and observational studies and requires confirmation in clinical intervention studies.

Vitamin D Toxicity
Although vitamin D toxicity is rare, too much can cause high levels of calcium concentrations or hypercalcemia. Hypercalcemia
can lead to a large amount of calcium to be excreted through the urine which can cause kidney damage. Calcium deposits may also
develop in soft tissues such as the kidneys, blood vessels, or other parts of the cardiovascular system. However, it is important to
know that the synthesis of vitamin D from the sun does not cause vitamin D toxicity due to the skin production of vitamin D3 being
a tightly regulated process.

Dietary Reference Intake for Vitamin D

The Institute of Medicine RDAs for vitamin D for different age groups is listed in Table . For adults, the RDA is 600
international units (IUs), which is equivalent to 15 micrograms of vitamin D. The National Osteoporosis Foundation recommends
slightly higher levels and that adults under age fifty get between 400 and 800 international units of vitamin D every day, and adults

7.2.6 [Link]
fifty and older get between 800 and 1,000 international units of vitamin D every day. According to the IOM, the tolerable upper
intake level (UL) for vitamin D is 4,000 international units per day. Toxicity from excess vitamin D is rare, but certain diseases
such as hyperparathyroidism, lymphoma, and tuberculosis make people more sensitive to the increases in calcium caused by high
intakes of vitamin D.
Table : Dietary Reference Intakes for Vitamin D

Age Group RDA (mcg/day) UL (mcg/day)

Infant (0–6 months) 10* 25

Infants (6–12 months) 10* 25

Children (1–3 years) 15 50

Children (4–8 years) 15 50

Children (9–13 years) 15 50

Adolescents (14–18 years) 15 50

Adults (19–71 years) 15 50

Adults (> 71 years) 20 50

* denotes Adequate Intake

Source: Ross, A. C. et al. (2011). The 2011 Report on Dietary Reference Intakes for Calcium and Vitamin D from the Institute of
Medicine: What Clinicians Need to Know. Journal of Clinical Endocrinology & Metabolism, 96(1), 53–8.
[Link] Accessed October 10, 2017.

Dietary Sources of Vitamin D

Table : Vitamin D Content of Various Foods

Food Serving Vitamin D (IU) Percent Daily Value

Swordfish 3 oz. 566 142

Salmon 3 oz. 447 112

Tuna fish, canned in water,

3 oz. 154 39
drained

Orange juice fortified with

1 c. 137 34
vitamin D

Milk, nonfat, reduced fat, and

1 c. 115-124 29-31
whole, vitamin D- fortified

Margarine, fortified 1 tbsp. 60 15

Sardines, canned in oil, drained 2 e. 46 12

Beef liver 3 oz. 42 11

Egg, large 1 e. 41 10

Source: Dietary Supplement Fact Sheet: Vitamin D. National Institutes of Health, Office of Dietary
[Link]://[Link]/factsheets/VitaminD-HealthProfessional/#h3. Updated September 5, 2012. Accessed October
22, 2017.

7.2.7 [Link]
Vitamin E Functions and Health Benefits
Vitamin E occurs in eight chemical forms, of which alpha-tocopherol appears to be the only form that is recognized to meet human
requirements. Alpha-tocopherol and vitamin E’s other constituents are fat-soluble and primarily responsible for protecting cell
membranes against lipid destruction caused by free radicals, therefore making it an antioxidant. When alpha-tocopherol interacts
with a free radical it is no longer capable of acting as an antioxidant unless it is enzymatically regenerated. Vitamin C helps to
regenerate some of the alpha-tocopherol, but the remainder is eliminated from the body. Therefore, to maintain vitamin E levels,
you ingest it as part of your diet.
Insufficient levels are rare (signs and symptoms of such conditions are not always evident) but are primarily the result of nerve
degeneration. People with malabsorption disorders, such as Crohn’s disease or cystic fibrosis, and babies born prematurely, are at
higher risk for vitamin E deficiency.
Vitamin E has many other important roles and functions in the body such as boosting the immune system by helping to fight off
bacteria and viruses. It also enhances the dilation of blood vessels and inhibiting the formation of blood clotting. Despite vitamin
E’s numerous beneficial functions when taken in recommended amounts, large studies do not support the idea that taking higher
doses of this vitamin will increase its power to prevent or reduce disease risk.[5][6]
Fat in the diet is required for vitamin E absorption as it is packaged into lipid-rich chylomicrons in intestinal cells and transported
to the liver. The liver stores some of the vitamin E or packages it into lipoproteins, which deliver it to cells.

Cardiovascular Disease
Vitamin E reduces the oxidation of LDLs, and it was therefore hypothesized that vitamin E supplements would protect against
atherosclerosis. However, large clinical trials have not consistently found evidence to support this hypothesis. In fact, in the
“Women’s Angiographic Vitamin and Estrogen Study,” postmenopausal women who took 400 international units (264 milligrams)
of vitamin E and 500 milligrams of vitamin C twice per day had higher death rates from all causes.[7]
Other studies have not confirmed the association between increased vitamin E intake from supplements and increased mortality.
There is more consistent evidence from observational studies that a higher intake of vitamin E from foods is linked to a decreased
risk of dying from a heart attack.

Cancer
The large clinical trials that evaluated whether there was a link between vitamin E and cardiovascular disease risk also looked at
cancer risk. These trials, called the HOPE-TOO Trial and Women’s Health Study, did not find that vitamin E at doses of 400
international units (264 milligrams) per day or 600 international units (396 milligrams) every other day reduced the risk of
developing any form of cancer.[8][9]

Eye Conditions
Oxidative stress plays a role in age-related loss of vision, called macular degeneration. Age-related macular degeneration (AMD)
primarily occurs in people over age fifty and is the progressive loss of central vision resulting from damage to the center of the
retina, referred to as the macula. There are two forms of AMD, dry and wet, with wet being the more severe form.
In the dry form, deposits form in the macula; the deposits may or may not directly impair vision, at least in the early stages of the
disease. In the wet form, abnormal blood vessel growth in the macula causes vision loss. Clinical trials evaluating the effects of
vitamin E supplements on AMD and cataracts (clouding of the lens of an eye) did not consistently observe a decreased risk for
either. However, scientists do believe vitamin E in combination with other antioxidants such as zinc and copper may slow the
progression of macular degeneration in people with early-stage disease.

Dementia
The brain’s high glucose consumption makes it more vulnerable than other organs to oxidative stress. Oxidative stress has been
implicated as a major contributing factor to dementia and Alzheimer’s disease. Some studies suggest vitamin E supplements delay
the progression of Alzheimer’s disease and cognitive decline, but again, not all of the studies confirm the relationship. A recent
study with over five thousand participants published in the July 2010 issue of the Archives of Neurology demonstrated that people

7.2.8 [Link]
with the highest intakes of dietary vitamin E were 25 percent less likely to develop dementia than those with the lowest intakes of
vitamin E.[10]
More studies are needed to better assess the dose and dietary requirements of vitamin E and, for that matter, whether other
antioxidants lower the risk of dementia, a disease that not only devastates the mind, but also puts a substantial burden on loved
ones, caretakers, and society in general.

Vitamin E Toxicity
Currently, researchers have not found any adverse effects from consuming vitamin E in food. Although that may be the case,
supplementation of alpha-tocopherol in animals has shown to cause hemorrhage and disrupt blood coagulation. Extremely high
levels of vitamin E can interact with vitamin K-dependent clotting factors causing an inhibition of blood clotting.[11]

Dietary Reference Intakes for Vitamin E

The Recommended Dietary Allowances (RDAs) and Tolerable Upper Intake Levels (ULs) for different age groups for vitamin E
are given in Table .
Table : Dietary Reference Intakes for Vitamin E

Age Group RDA Males and Females mg/day UL

Infants (0–6 months) 4* –

Infants (7–12 months) 5* –

Children (1–3 years) 6 200

Children (4–8 years) 7 300

Children (9–13 years) 11 600

Adolescents (14–18 years) 15 800

Adults (> 19 years) 15 1,000

*denotes Adequate Intake

Source: Dietary Supplement Fact Sheet: Vitamin [Link] Institutes of Health, Office of Dietary Supplements.
[Link] Updated October 11, 2011. Accessed October 5, 2017.
Vitamin E supplements often contain more than 400 international units, which is almost twenty times the RDA. The UL for vitamin
E is set at 1,500 international units for adults. There is some evidence that taking vitamin E supplements at high doses has negative
effects on health. As mentioned, vitamin E inhibits blood clotting and a few clinical trials have found that people taking vitamin E
supplements have an increased risk of stroke. In contrast to vitamin E from supplements, there is no evidence that consuming foods
containing vitamin E compromises health.

Dietary Sources of Vitamin E

Add some nuts to your salad and make your own dressing to get a healthy dietary dose of vitamin E.

7.2.9 [Link]
 Figure : Image by [Link] on
[Link] / CC0
Vitamin E is found in many foods, especially those higher in fat, such as nuts and oils. Some spices, such as paprika and red chili
pepper, and herbs, such as oregano, basil, cumin, and thyme, also contain vitamin E. (Keep in mind spices and herbs are commonly
used in small amounts in cooking and therefore are a lesser source of dietary vitamin E.) See Table for a list of foods and their
vitamin E contents.

 Everyday Connection

To increase your dietary intake of vitamin E from plant-based foods try a spinach salad with tomatoes and sunflower seeds, and
add a dressing made with sunflower oil, oregano, and basil.

Table : Vitamin E Content of Various Foods

Food Serving Size Vitamin E (mg) Percent Daily Value

Sunflower seeds 1 oz. 7.4 37

Almonds 1 oz. 6.8 34

Sunflower oil 1 Tbsp 5.6 28

Hazelnuts 1 oz. 1 oz. 4.3 22

Peanut butter 2 Tbsp. 2.9 15

Peanuts 1 oz. 1 oz. 2.2 11

Corn oil 1 Tbsp. 1 Tbsp. 1.9 10

Kiwi 1 medium 1.1 6

Tomato 1 medium 0.7 4

Spinach 1 c. raw 0.6 3

Source: Dietary Supplement Fact Sheet: Vitamin [Link] Institutes of Health, Office of Dietary Supplements.
[Link] Updated October 11, 2011. Accessed October 5, 2017.

Vitamin K Functions and Health Benefits

Vitamin K refers to a group of fat-soluble vitamins that are similar in chemical structure. Vitamin K is critical for blood function
acting as coenzymes which play an essential role in blood coagulation (aka blood clotting). Blood-clotting proteins are

7.2.10 [Link]
continuously circulating in the blood. Upon injury to a blood vessel, platelets stick to the wound forming a plug. Without vitamin
K, blood would not clot.
A deficiency in vitamin K causes bleeding disorders. It is relatively rare, but people who have liver or pancreatic disease, celiac
disease, or malabsorption conditions are at higher risk for vitamin K deficiency. Signs and symptoms include nosebleeds, easy
bruising, broken blood vessels, bleeding gums, and heavy menstrual bleeding in women. The function of the anticoagulant drug
warfarin is impaired by excess vitamin K intake from supplements. Calcium additionally plays a role in activation of blood-clotting
proteins.

Bone Health
Vitamin K is also required for maintaining bone health. It modifies the protein osteocalcin, which is involved in the bone
remodeling process. All the functions of osteocalcin and the other vitamin K-dependent proteins in bone tissue are not well
understood and are under intense study. Some studies do show that people who have diets low in vitamin K also have an increased
risk for bone fractures.

Dietary Reference Intake and Food Sources for Vitamin K

The AI of vitamin K for adult females is 90 micrograms per day, and for males it is 120 micrograms per day. A UL for vitamin K
has not been set. The Food and Nutrition Board (FNB) has not established an UL for vitamin K because it has a low potential for
toxicity. According to the FNB, “no adverse effects associated with vitamin K consumption from food or supplements have been
reported in humans or animals.”
Institute of Medicine. Dietary reference intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron,
manganese, molybdenum, nickel, silicon, vanadium, and zinc. Washington, DC: National Academy Press; 2001.
Table : Dietary Reference Intakes for Vitamin K

Age Group RDA (mcg/day)

Infants (0–6 months) 2.0*

Infants (6–12 months) 2.5*

Children (1–3 years) 30

Children (4–8 years) 55

Children (9–13 years) 60

Adolescents (14–18 years) 75

Adult Males (> 19 years) 120

Adult Females (> 19 years) 90

* denotes Adequate Intake

Source: Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese,
Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Institute of Medicine. [Link]/Reports/2001/Dietary-Reference-Intakes-
for-Vitamin-A-Vitamin-K-Arsenic-Boron-Chromium-Copper-Iodine-Iron-Manganese-Molybdenum-Nickel-Silicon-Vanadium-and-
[Link]. Published January 9, 2001. Accessed October 10, 2017.

Dietary Sources of Vitamin K

Vitamin K is present in many foods. It is found in highest concentrations in green vegetables such as broccoli, cabbage, kale,
parsley, spinach, and lettuce. Additionally, vitamin K can be synthesized via bacteria in the large intestine. The exact amount of
vitamin K synthesized by bacteria that is actually absorbed in the lower intestine is not known, but likely contributes less than 10
percent of the recommended intake. Newborns have low vitamin K stores and it takes time for the sterile newborn gut to acquire
the good bacteria it needs to produce vitamin K. So, it has become a routine practice to inject newborns with a single intramuscular
dose of vitamin K. This practice has basically eliminated vitamin K-dependent bleeding disorders in babies.

7.2.11 [Link]
 Table : Dietary Sources of Vitamin K

Food Serving Vitamin K (mcg) Percent Daily Value

Broccoli ½ c. 160 133

Asparagus 4 spears 34 28

Cabbage ½ c. 56 47

Spinach ½ c. 27 23

Green peas ½ c. 16 13

Cheese 1 oz. 10 8

Ham 3 oz. 13 11

Ground beef 3 oz. 6 5

Bread 1 slice 1.1 <1

Orange 1 e. 1.3 1

Summary of Fat-soluble Vitamins

Table : Fat-Soluble Vitamins

7.2.12 [Link]
 Recommended Deficiency
Major Groups at risk
Vitamin Sources Intake for diseases and Toxicity UL
functions of deficiency
adults symptoms

People living
in poverty
Retinol: beef
(especially Hypervitamin
and chicken Xerophthalmi
infants and osis A: Dry,
liver, skim a, night
Vitamin A Antioxidant,vi children), itchy skin,
milk, whole blindness, eye
(retinol, sion, cell premature hair loss, liver
milk, cheddar infections;
retinal, 700-900 differentiation, infants, damage, joint
cheese; poor growth, 3000 mcg/day
retinoic mcg/day reproduction, pregnant and pain,
Carotenoids: dry skin,
acid,carotene, immune lactating fractures, birth
pumpkin, impaired
beta-carotene) function women people defects,
carrots, immune
who consume swelling of the
squash, function
low-fat or brain
collards, peas
low-protein
diets

Rickets in
Swordfish,
children:
salmon, tuna, Breastfed Calcium
Absorption abnormal
orange juice infants, older deposits in
and regulation growth,
(fortified), 600-800 adults people soft tissues,
of calcium and misshapen 4000 IU/day
Vitamin D milk IU/day (15-20 with limited damage to the
phosphorus, bones, bowed (100 mcg/day)
(fortified), mcg/day) sun exposure, heart, blood
maintenance legs, soft
sardines, egg, people with vessels, and
of bone bones;
synthesis from dark skin kidneys
osteomalacia
sunlight
in adults

Sunflower People with

Inhibition of 1000 mcg/day
seeds, Antioxidant, Broken red poor fat
vitamin K from
Vitamin E almonds, 15 mg/day protects cell blood cells, absorption,
clotting supplemental
hazelnuts,pean membranes nerve damage premature
factors sources
uts infants

Synthesis of
blood clotting
Vegetable oils,
proteins and Newborns,
leafy greens,
90-120 proteins people on long Anemia, brain
Vitamin K synthesis by Hemorrhage ND
mcg/day needed for term damage
intestinal
bone health antibiotics
bacteria
and cell
growth

Learning Activities
An interactive or media element has been excluded from this version of the text. You can view it online here:
[Link]/humannutrition2/?p=331
1. Sommer A. (2008). Vitamin A Deficiency and Clinical Disease: An Historical Overview. Journal of Nutrition, 138, 1835–39.
[Link]/content/138/10/[Link]. Accessed October 4, 2017. ↵
2. Goodman GE, et al. (2004). The Beta-Carotene and Retinol Efficacy Trial: Incidence of Lung Cancer and Cardiovascular
Disease Mortality During 6-year Follow-up after Stopping Beta-Carotene and Retinol Supplements. Journal of the National
Cancer Institute, 96(23), 1743–50. [Link]/content/96/23/[Link]. Accessed October 6, 2017. ↵

7.2.13 [Link]
 3. Dietary Supplement Fact Sheet: Vitamin A. National Institutes of Health, Office of Dietary Supplements.
[Link] Updated September 5, 2012. Accessed October 7, 2017. ↵
4. Bischoff-Ferrari, HA, et al. (2005). Fracture Prevention with Vitamin D Supplementation: A Meta-Analysis of Randomized
Controlled Trials. Journal of the American Medical Association, 293(18), 2257–64. [Link]
[Link]/content/293/18/[Link]. Accessed October 12, 2017. ↵
5. Goodman M, Bostlick RM, Kucuk O, Jones DP. (2011). Clinical trials of antioxidants as cancer prevention agents: past, present,
and future. Free Radical Biology & Medicine, 51(5), 1068–84. [Link] Accessed
October 5, 2017. ↵
6. McGinley C, Shafat A. Donnelly AE. (2009). Does antioxidant vitamin supplementation protect against muscle damage. Sports
Medicine, 39(12), 1011–32. [Link] Accessed October 5, 2017. ↵
7. Waters DD, et al. (2002). Effects of Hormone Replacement Therapy and Antioxidant Vitamin Supplements on Coronary
Atherosclerosis in Postmenopausal Women: A Randomized Controlled Trial. The Journal of the American Medical Association,
288(19), 2432–40. [Link] Accessed October 5, 2017. ↵
8. HOPE and HOPE-TOO Trial Investigators. (2005). Effects of Long-Term Vitamin E Supplementation on Cardiovascular Events
and Cancer. The Journal of the American Medical Association, 293, 1338–47. [Link]
[Link]/content/293/11/[Link]., Accessed October 5, 2017. ↵
9. Lee IM, et al. (2005). Vitamin E in the Primary Prevention of Cardiovascular Disease and Cancer: The Women’s Health Study.
The Journal of the American Medical Association, 294, 56–65. [Link] Accessed
October 5, 2017. ↵
10. Devore EE, et al. (2010). Dietary Antioxidants and Long-Term Risk of Dementia, Archives of Neurology, 67(7), 819–25.
[Link] Accessed October 5, 2017. ↵
11. Dietary Supplement Fact Sheet: Vitamin [Link] Institutes of Health, Office of Dietary Supplements.
[Link] Updated October 11, 2011. Accessed October 5, 2017. ↵

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9.2: Fat-Soluble Vitamins by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original
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7.2.14 [Link]
7.3: Water-Soluble Vitamins
All water-soluble vitamins play a different kind of role in energy metabolism; they are required as functional parts of enzymes
involved in energy release and storage. Vitamins and minerals that make up part of enzymes are referred to as coenzymes and
cofactors, respectively. Coenzymes and cofactors are required by enzymes to catalyze a specific reaction. They assist in converting
a substrate to an end-product. Coenzymes and cofactors are essential in catabolic pathways and play a role in many anabolic
pathways too. In addition to being essential for metabolism, many vitamins and minerals are required for blood renewal and
function. At insufficient levels in the diet these vitamins and minerals impair the health of blood and consequently the delivery of
nutrients in and wastes out, amongst its many other functions. In this section we will focus on the vitamins that take part in
metabolism and blood function and renewal.

Figure : Enzyme Active Site for Cofactors. Coenzymes and cofactors are the
particular vitamin or mineral required for enzymes to catalyze a specific reaction.

Vitamin C
Vitamin C, also commonly called ascorbic acid, is a water[-soluble micronutrient essential in the diet for humans, although most
other mammals can readily synthesize it. Vitamin C’s ability to easily donate electrons makes it a highly effective antioxidant. It is
effective in scavenging reactive oxygen species, reactive nitrogen species, and many other free radicals. It protects lipids both by
disabling free radicals and by aiding in the regeneration of vitamin E.
In addition to its role as an antioxidant, vitamin C is a required part of several enzymes like signaling molecules in the brain, some
hormones, and ]amino acids. Vitamin C is also essential for the synthesis and maintenance of collagen. Collagen is the most
abundant protein in the body and used for different functions such as the structure for ligaments, tendons, and blood vessels and
also scars that bind wounds together. Vitamin C acts as the glue that holds the collagen fibers together and without sufficient levels
in the body, collagen strands are weak and abnormal. (Figure )

7.3.1 [Link]
 Figure : The
Role of Vitamin C in Collagen Synthesis. Image by Allison Calabrese / CC BY 4.0
Vitamin C levels in the body are affected by the amount in the diet, which influences how much is absorbed and how much the
kidney allows to be excreted, such that the higher the intake, the more vitamin C is excreted. Vitamin C is not stored in any
significant amount in the body, but once it has reduced a free radical, it is very effectively regenerated and therefore it can exist in
the body as a functioning antioxidant for many weeks.
The classic condition associated with vitamin C deficiency is scurvy. The signs and symptoms of scurvy include skin disorders,
bleeding gums, painful joints, weakness, depression, and increased susceptibility to infections. Scurvy is prevented by having an
adequate intake of fruits and vegetables rich in vitamin C.

Figure : Bleeding Gums Associated with Scurvy. Scorbutic

gums due to a vitamin C deficiency, a symptom of scurvy. [Link]/wiki/F...butic_gums.jpg

Cardiovascular Disease
Vitamin C’s ability to prevent disease has been debated for many years. Overall, higher dietary intakes of vitamin C (via food
intake, not supplements), are linked to decreased disease risk. A review of multiple studies published in the April 2009 issue of the
Archives of Internal Medicine concludes there is moderate scientific evidence supporting the idea that higher dietary vitamin C

7.3.2 [Link]
intakes are correlated with reduced cardiovascular disease risk, but there is insufficient evidence to conclude that taking vitamin C
supplements influences cardiovascular disease risk.[1] Vitamin C levels in the body have been shown to correlate well with fruit and
vegetable intake, and higher plasma vitamin C levels are linked to reduced risk of some chronic diseases. In a study involving over
twenty thousand participants, people with the highest levels of circulating vitamin C had a 42 percent decreased risk for having a
stroke.[2]

Cancer
There is some evidence that a higher vitamin C intake is linked to a reduced risk of cancers of the mouth, throat, esophagus,
stomach, colon, and lung, but not all studies confirm this is true. As with the studies on cardiovascular disease, the reduced risk of
cancer is the result of eating foods rich in vitamin C, such as fruits and vegetables, not from taking vitamin C supplements. In these
studies, the specific protective effects of vitamin C cannot be separated from the many other beneficial chemicals in fruits and
vegetables.

Immunity
Vitamin C does have several roles in the immune system, and many people increase vitamin C intake either from diet or
supplements when they have a cold. Many others take vitamin C supplements routinely to prevent colds. Contrary to this popular
practice, however, there is no good evidence that vitamin C prevents a cold. A review of more than fifty years of studies published
in 2004 in the Cochrane Database of Systematic Reviews concluded that taking vitamin C routinely does not prevent colds in most
people, but it does slightly reduce cold severity and duration. Moreover, taking megadoses (up to 4 grams per day) at the onset of a
cold provides no benefits.[3]
Gout is a disease caused by elevated circulating levels of uric acid and is characterized by recurrent attacks of tender, hot, and
painful joints. There is some evidence that a higher intake of vitamin C reduces the risk of gout.

Vitamin C Toxicity
High doses of vitamin C have been reported to cause numerous problems, but the only consistently shown side effects are
gastrointestinal upset and diarrhea. To prevent these discomforts the IOM has set a UL for adults at 2,000 milligrams per day
(greater than twenty times the RDA).
At very high doses in combination with iron, vitamin C has sometimes been found to increase oxidative stress, reaffirming that
getting your antioxidants from foods is better than getting them from supplements, as that helps regulate your intake levels. There
is some evidence that taking vitamin C supplements at high doses increases the likelihood of developing kidney stones, however,
this effect is most often observed in people that already have multiple risk factors for kidney stones.

Dietary Reference Intakes for Vitamin C

The RDAs and ULs for different age groups for vitamin C are listed in Table . They are considered adequate to prevent scurvy.
Vitamin C’s effectiveness as a free radical scavenger motivated the Institute of Medicine (IOM) to increase the RDA for smokers
by 35 milligrams, as tobacco smoke is an environmental and behavioral contributor to free radicals in the body.
Table : Dietary Reference Intakes for Vitamin C

7.3.3 [Link]
 Age Group RDA Males and Females mg/day UL

Infants (0–6 months) 40* –

Infants (7–12 months) 50* –

Children (1–3 years) 15 400

Children (4–8 years) 25 650

Children (9–13 years) 45 1200

Adolescents (14–18 years) 75 (males), 65 (females) 1800

Adults (> 19 years) 90 (males), 75 (females) 2000

*denotes Adequate Intake

Source: Dietary Supplement Fact Sheet: Vitamin C. National Institutes of Health, Office of Dietary Supplements.
[Link] Updated June 24, 2011. Accessed October 5, 2017.

Dietary Sources of Vitamin C

Citrus fruits are great sources of vitamin C and so are many vegetables. In fact, British sailors in the past were often referred to as
“limeys” as they carried sacks of limes onto ships to prevent scurvy. Vitamin C is not found in significant amounts in animal-based
foods.
Because vitamin C is water-soluble, it leaches away from foods considerably during cooking, freezing, thawing, and canning. Up to
50 percent of vitamin C can be boiled away. Therefore, to maximize vitamin C intake from foods, you should eat fruits and
vegetables raw or lightly steamed. For the vitamin C content of various foods, see Table 9.12.
Table : Vitamin C Content of Various Foods

Food Serving Vitamin C (mg) Percent Daily Value

Orange juice 6 oz. 93 155

Grapefruit juice 6 oz. 70 117

Orange 1 medium 70 117

Strawberries 1 c. 85 164

Tomato 1 medium 17 28

Sweet red pepper ½ c. raw 95 158

Broccoli ½ c. cooked 51 65

Romaine lettuce 2 c. 28 47

Cauliflower 1 c. boiled 55 86

Potato 1 medium, baked 17 28

Source: Dietary Supplement Fact Sheet: Vitamin C. National Institutes of Health, Office of Dietary Supplements.
[Link] Updated June 24, 2011. Accessed October 5, 2017.

Thiamin (B1 )
Thiamin is especially important in glucose metabolism. It acts as a cofactor for enzymes that break down glucose for energy
production (Figure 9.7 “Enzyme Active Site for Cofactors” ). Thiamin plays a key role in nerve cells as the glucose that is

7.3.4 [Link]
catabolized by thiamin is needed for an energy source. Additionally, thiamin plays a role in the synthesis of neurotransmitters and is
therefore required for RNA, DNA, and ATP synthesis.
The brain and heart are most affected by a deficiency in thiamin. Thiamin deficiency, also known as beriberi, can cause symptoms
of fatigue, confusion, movement impairment, pain in the lower extremities, swelling, and heart failure. It is prevalent in societies
whose main dietary staple is white rice. During the processing of white rice, the bran is removed, along with what were called in
the early nineteenth century, “accessory factors,” that are vital for metabolism. Dutch physician Dr. Christiaan Eijkman cured
chickens of beriberi by feeding them unpolished rice bran in 1897. By 1912, Sir Frederick Gowland Hopkins determined from his
experiments with animals that the “accessory factors,” eventually renamed vitamins, are needed in the diet to support growth, since
animals fed a diet of pure carbohydrates, proteins, fats, and minerals failed to grow.[4]Eijkman and Hopkins were awarded the
Nobel Prize in Physiology (or Medicine) in 1929 for their discoveries in the emerging science of nutrition.
Another common thiamin deficiency known as Wernicke- Korsakoff syndrome can cause similar symptoms as beriberi such as
confusion, loss of coordination, vision changes, hallucinations, and may progress to coma and death. This condition is specific to
alcoholics as diets high in alcohol can cause thiamin deficiency. Other individuals at risk include individuals who also consume
diets typically low in micronutrients such as those with eating disorders, elderly, and individuals who have gone through gastric
bypass surgery.[5]

7.3.5 [Link]
 Figure : The Role of Thiamin. Image by Allison

Calabrese / CC BY 4.0 Figure : Beriberi, Thiamin

Deficiency. Image by Casimir Funk (1914) / No known copyright restrictions

Dietary Reference Intakes

The RDAs and ULs for different age groups for thiamin are listed in Table . There is no UL for thiamin because there has not
been any reports on toxicity when excess amounts are consumed from food or supplements.

7.3.6 [Link]
 Table : Dietary Reference Intakes for Thiamin

Age Group RDA Males and Females mg/day

Infants (0–6 months) 0.2 *

Infants (7–12 months) 0.3

Children (1–3 years) 0.5

Children (4–8 years) 0.6

Children (9–13 years) 0.9

Adolescents (14–18 years) 1.2 (males), 1.0 (females)

Adults (> 19 years) 1.2 (males), 1.1 (females)

*denotes Adequate Intake

Health Professional Fact Sheet: Thiamin. National Institutes of Health, Office of Dietary
[Link]://[Link]/factsheets/Thiamin-HealthProfessional/ . Updated February 11, 2016 . Accessed October 5,
2017.

Dietary Sources
Whole grains, meat and fish are great sources of thiamin. The United States as well as many other countries, fortify their refined
breads and cereals. For the thiamin content of various foods, see Table 9.14.
Table : Thiamin Content of Various Foods

Food Serving Thiamin (mg) Percent Daily Value

Breakfast cereals, fortified 1 serving 1.5 100

White rice, enriched ½ c. 1.4 73

Pork chop, broiled 3 oz. 0.4 27

Black beans, boiled ½ c. 0.4 27

Tuna, cooked 3 oz. 0.2 13

Brown rice, cooked, not

½ c. 0.1 7
enriched

Whole wheat bread 1 slice 0.1 7

2% Milk 8 oz. 0.1 7

Cheddar cheese 1 ½ oz 0 0

Apple, sliced 1 c. 0 0

Health Professional Fact Sheet: Thiamin. National Institutes of Health, Office of Dietary
[Link]://[Link]/factsheets/Thiamin-HealthProfessional/ . Updated February 11, 2016 . Accessed October 5,
2017.

Riboflavin (B2)
Riboflavin is an essential component of flavoproteins, which are coenzymes involved in many metabolic pathways of carbohydrate,
lipid, and protein metabolism. Flavoproteins aid in the transfer of electrons in the electron transport chain. Furthermore, the
functions of other B-vitamin coenzymes, such as vitamin B6 and folate, are dependent on the actions of flavoproteins. The “flavin”

7.3.7 [Link]
portion of riboflavin gives a bright yellow color to riboflavin, an attribute that helped lead to its discovery as a vitamin. When
riboflavin is taken in excess amounts (supplement form) the excess will be excreted through your kidneys and show up in your
urine. Although the color may alarm you, it is harmless. There are no adverse effects of high doses of riboflavin from foods or
supplements that have been reported.
Riboflavin deficiency, sometimes referred to as ariboflavinosis, is often accompanied by other dietary deficiencies (most notably
protein) and can be common in people that suffer from alcoholism. This deficiency will usually also occur in conjunction with
deficiencies of other B vitamins because the majority of B vitamins have similar food sources. Its signs and symptoms include dry,
scaly skin, cracking of the lips and at the corners of the mouth, sore throat, itchy eyes, and light sensitivity.

Dietary Reference Intakes

The RDAs for different age groups for riboflavin are listed in Table . There is no UL for riboflavin because no toxicity has
been reported when an excess amount has been consumed through foods or supplements.
Table : Dietary Reference Intakes for Riboflavin
Age Group RDA Males and Females mg/day

Infants (0–6 months) 0.3 *

Infants (7–12 months) 0.4*

Children (1–3 years) 0.5

Children (4–8 years) 0.6

Children (9–13 years) 0.9

Adolescents (14–18 years) 1.3 (males), 1.0 (females)

Adults (> 19 years) 1.3 (males), 1.1 (females)

*denotes Adequate Intake

Fact Sheet for Health Professionals, Riboflavin. National Institute of Health, Office of Dietary Supplements.
[Link] Updated February 11, 2016. Accessed October 22, 2017.

Dietary Sources
Riboflavin can be found in a variety of different foods but it is important to remember that it can be destroyed by sunlight. Milk is
one of the best sources of riboflavin in the diet and was once delivered and packaged in glass bottles. This packaging has changed
to cloudy plastic containers or cardboard to help block the light from destroying the riboflavin in milk. For the riboflavin content of
various foods, see Table .
Table : Riboflavin Content of Various Foods

7.3.8 [Link]
 Food Serving Riboflavin (mg) Percent Daily Value

Beef liver 3 oz. 2.9 171

Breakfast cereals, fortified 1 serving 1.7 100

Instant oats, fortified 1 c. 1.1 65

Plain yogurt, fat free 1 c. 0.6 35

2% milk 8 oz. 0.5 29

Beef, tenderloin steak 3 oz. 0.4 24

Portabella mushrooms, sliced ½ c. 0.3 18

Almonds, dry roasted 1 oz. 0.3 18

Egg, scrambled 1 large 0.2 12

Quinoa 1 c. 0.2 12

Salmon, canned 3 oz. 0.2 12

Spinach, raw 1 c. 0.1 6

Brown rice ½ c. 0 0

Fact Sheet for Health Professionals, Riboflavin. National Institute of Health, Office of Dietary Supplements.
[Link] Updated February 11, 2016. Accessed October 22, 2017.

Niacin (B3)
Niacin is a component of the coenzymes NADH and NADPH, which are involved in the catabolism and/or anabolism of
carbohydrates, lipids, and proteins. NADH is the predominant electron carrier and transfers electrons to the electron-transport chain
to make ATP. NADPH is also required for the anabolic pathways of fatty-acid and cholesterol synthesis. In contrast to other
vitamins, niacin can be synthesized by humans from the amino acid tryptophan in an anabolic process requiring enzymes
dependent on riboflavin, vitamin B6, and iron. Niacin is made from tryptophan only after tryptophan has met all of its other needs
in the body. The contribution of tryptophan-derived niacin to niacin needs in the body varies widely and a few scientific studies
have demonstrated that diets high in tryptophan have very little effect on niacin deficiency. Niacin deficiency is commonly known
as pellagra and the symptoms include fatigue, decreased appetite, and indigestion. These symptoms are then commonly followed
by the four D’s: diarrhea, dermatitis, dementia, and sometimes death.

7.3.9 [Link]
 Figure : Conversion of Tryptophan to Niacin.

Image by Allison Calabrese / CC BY 4.0 Figure : Niacin Deficiency, Pellagra. Image by

Herbert L. Fred, MD, Hendrik A. van Dijk / CC BY-SA 3.0

Dietary Reference Intakes

The RDAs and ULs for different age groups for Niacin are listed in Table 9.17. Because Niacin needs can be met from tryptophan,
The RDA is expressed in niacin equivalents (NEs). The conversions of NE, Niacin, and tryptophan are: 1 mg NE= 60 mg
tryptophan= 1 mg niacin
Table : Dietary Reference Intakes for Niacin
Age Group RDA Males and Females mg NE/day) UL

Infants (0–6 months) 2* Not possible to establish

Infants (7–12 months) 4* Not possible to establish

Children (1–3 years) 6 10

Children (4–8 years) 8 15

Children (9–13 years) 12 20

Adolescents (14–18 years) 16 (males), 14 (females) 30

Adults (> 19 years) 16 (males), 14 (females) 35

*denotes Adequate Intake

7.3.10 [Link]
Micronutrient Information Center: Niacin. Oregon State University, Linus Pauling Institute.
[Link] Updated in July 2013. Accessed October 22, 2017.

Dietary Sources
Niacin can be found in a variety of different foods such as yeast, meat, poultry, red fish, and cereal. In plants, especially mature
grains, niacin can be bound to sugar molecules which can significantly decrease the niacin bioavailability. For the niacin content of
various foods, see Table .
Table : Niacin Content of Various Foods
Food Serving Niacin (mg) Percent Daily Value

Chicken 3 oz. 7.3 36.5

Tuna 3 oz. 8.6 43

Turkey 3 oz. 10.0 50

Salmon 3 oz. 8.5 42.5

Beef (90% lean) 3 oz. 4.4 22

Cereal (unfortified) 1 c. 5 25

Cereal (fortified) 1 c. 20 100

Peanuts 1 oz. 3.8 19

Whole wheat bread 1 slice 1.3 6.5

Coffee 8 oz. 0.5 2.5

Micronutrient Information Center: Niacin. Oregon State University, Linus Pauling Institute.
[Link] Updated in July 2013. Accessed October 22, 2017.

7.3.11 [Link]
Pantothenic Acid (B5)

Figure : Pantothenic Acid‘s

Role in the Citric Acid Cycle. Pantothenic Acid (Vitamin B5) makes up coenzyme A, which carries the carbons of glucose, fatty
acids, and amino acids into the citric acid cycle as Acetyl-CoA.
Pantothenic acid forms coenzyme A, which is the main carrier of carbon molecules in a cell. Acetyl-CoA is the carbon carrier of
glucose, fatty acids, and amino acids into the citric acid cycle (Figure 9.14 “Pantothenic Acid’s Role in the Citric Acid Cycle”).
Coenzyme A is also involved in the synthesis of lipids, cholesterol, and acetylcholine (a neurotransmitter). A Pantothenic Acid
deficiency is exceptionally rare. Signs and symptoms include fatigue, irritability, numbness, muscle pain, and cramps. You may
have seen pantothenic acid on many ingredients lists for skin and hair care products; however there is no good scientific evidence
that pantothenic acid improves human skin or hair.

Dietary Reference Intakes

Because there is little information on the requirements for pantothenic acids, the Food and Nutrition Board (FNB) has developed
Adequate Intakes (AI) based on the observed dietary intakes in healthy population groups. The AI for different age groups for
pantothenic acid are listed in Table .
Table : Dietary Reference Intakes for Pantothenic Acid

Age Group AI Males and Females mg/day)

Infants (0–6 months) 1.7

Infants (7–12 months) 1.8

Children (1–3 years) 2

Children (4–8 years) 3

Children (9–13 years) 4

Adolescents (14–18 years) 5

Adults (> 19 years) 5

7.3.12 [Link]
Micronutrient Information Center: Pantothenic Acid. Oregon State University, Linus Pauling Institute.
[Link] . Updated in July 2013. Accessed October 22, 2017.

Dietary Sources
Pantothenic Acid is widely distributed in all types of food, which is why a deficiency in this nutrient is rare. Pantothenic Acid gets
its name from the greek word “pantothen” which means “from everywhere”. For the pantothenic acid content of various foods, see
Table 9.20 Pantothenic Acid Content of Various Foods”.
Table : Pantothenic Acid Content of Various Foods
Food Serving Pantothenic Acid (mg) Percent Daily Value

Sunflower seeds 1 oz. 2 20

Fish, trout 3 oz. 1.9 19

Yogurt, plain nonfat 8 oz. 1.6 16

Lobster 3 oz. 1.4 14

Avocado ½ fruit 1 10

Sweet potato 1 medium 1 10

Milk 8 fl oz. 0.87 8.7

Egg 1 large 0.7 7

Orange 1 whole 0.3 3

Whole wheat bread 1 slice 0. 21 2.1

Micronutrient Information Center: Pantothenic Acid. Oregon State University, Linus Pauling Institute.
[Link] . Updated in July 2013. Accessed October 22, 2017.

Biotin
Biotin is required as a coenzyme in the citric acid cycle and in lipid metabolism. It is also required as an enzyme in the synthesis of
glucose and some nonessential amino acids. A specific enzyme, biotinidase, is required to release biotin from protein so that it can
be absorbed in the gut. There is some bacterial synthesis of biotin that occurs in the colon; however this is not a significant source
of biotin. Biotin deficiency is rare, but can be caused by eating large amounts of egg whites over an extended period of time. This is
because a protein in egg whites tightly binds to biotin making it unavailable for absorption. A rare genetic disease-causing
malfunction of the biotinidase enzyme also results in biotin deficiency. Symptoms of biotin deficiency are similar to those of other
B vitamins, but may also include hair loss when severe.

Dietary Reference Intakes

Because there is little information on the requirements for biotin, the FNB has developed Adequate Intakes (AI) based on the
observed dietary intakes in healthy population groups. The AI for different age groups for biotin are listed in Table .
Table : Dietary Reference Intakes for Biotin

7.3.13 [Link]
 Age Group AI Males and Females mcg/day)

Infants (0–6 months) 5

Infants (7–12 months) 6

Children (1–3 years) 8

Children (4–8 years) 12

Children (9–13 years) 20

Adolescents (14–18 years) 25

Adults (> 19 years) 30

Fact Sheet for Health Professionals: Biotin. National Institute of Health, Office of Dietary Supplements.
[Link] Updated October 3, 2017. Accessed November 10, 2017.

Dietary Sources
Biotin can be found in foods such as eggs, fish, meat, seeds, nuts and certain vegetables. For the pantothenic acid content of various
foods, see Table .
Table : Biotin Content of Various Foods

Food Serving Biotin (mcg) Percent Daily Value*

Eggs 1 large 10 33.3

Salmon, canned 3 oz. 5 16.6

Pork chop 3 oz. 3.8 12.6

Sunflower seeds ¼ c. 2.6 8.6

Sweet potato ½ c. 2.4 8

Almonds ¼ c. 1.5 5

Tuna, canned 3 oz. 0.6 2

Broccoli ½ c. 0.4 1.3

Banana ½ c. 0.2 0.6

* Current AI used to determine

Percent Daily Value

Fact Sheet for Health Professionals: Biotin. National Institute of Health, Office of Dietary Supplements.
[Link] Updated October 3, 2017. Accessed November 10, 2017.

Vitamin B6 (Pyridoxine)
Vitamin B6 is the coenzyme involved in a wide variety of functions in the body. One major function is the nitrogen transfer
between amino acids which plays a role in amino-acid synthesis and catabolism. Also, it functions to release glucose from glycogen
in the catabolic pathway of glycogenolysis and is required by enzymes for the synthesis of multiple neurotransmitters and
hemoglobin (Figure ).
Vitamin B6 is also a required coenzyme for the synthesis of hemoglobin. A deficiency in vitamin B6 can cause anemia, but it is of a
different type than that caused by insufficient folate, cobalamin, or iron; although the symptoms are similar. The size of red blood
cells is normal or somewhat smaller but the hemoglobin content is lower. This means each red blood cell has less capacity for

7.3.14 [Link]
carrying oxygen, resulting in muscle weakness, fatigue, and shortness of breath. Other deficiency symptoms of vitamin B6 can
cause dermatitis, mouth sores, and confusion.

Figure : The
Function of Vitamin B6 in Amino Acid Metabolism. Image by Allison Calabrese / CC BY 4.0
The vitamin B6 coenzyme is needed for a number of different reactions that are essential for amino acid synthesis, catabolism for
energy, and the synthesis of glucose and neurotransmitters.

Figure : Vitamin B6 Functional

Coenzyme Role. Image by Allison Calabrese / CC BY 4.0

7.3.15 [Link]
Vitamin B6 coenzyme is essential for the conversion of amino acid methionine into cysteine. With low levels of Vitamin B6,
homocysteine will build up in the blood. High levels of homocysteine increases the risk for heart disease.

Vitamin B6 Toxicity
Currently, there are no adverse effects that have been associated with a high dietary intake of vitamin B6, but large supplemental
doses can cause severe nerve impairment. To prevent this from occurring, the UL for adults is set at 100 mg/day.

Dietary Reference Intakes

The RDAs and ULs for different age groups for vitamin B6 are listed in Table .
Table : Dietary Reference Intakes for Vitamin B6

Age Group RDA Males and Females mg/day UL

Infants (0–6 months) 0.1* Not possible to determine

Infants (7–12 months) 0.3* Not possible to determine

Children (1–3 years) 0.5 30

Children (4–8 years) 0.6 40

Children (9–13 years) 1 60

Adolescents (14–18 years) 1.3 (males), 1.2 (females) 80

Adults (> 19 years) 1.3 100

*denotes Adequate Intake

Dietary Supplement Fact Sheet: Vitamin B6. National Institute of Health, Office of Dietary Supplements.
[Link] Updates February 11, 2016. Accessed October 22, 2017.

Dietary Sources
Vitamin B6 can be found in a variety of foods. The richest sources include fish, beef liver and other organ meats, potatoes, and
other starchy vegetables and fruits. For the Vitamin B6 content of various foods, see Table 9.24 Vitamin B6 Content of Various
Foods”.
Table : Vitamin B6 Content of Various Foods
Food Serving Vitamin B6 (mg) Percent Daily Value

Chickpeas 1 c. 1.1 55

Tuna, fresh 3 oz. 0.9 45

Salmon 3 oz. 0.6 30

Potatoes 1 c. 0.4 20

Banana 1 medium 0.4 20

Ground beef patty 3 oz. 0.3 10

White rice, enriched 1 c. 0.1 5

Spinach ½c 0.1 5

Dietary Supplement Fact Sheet: Vitamin B6. National Institute of Health, Office of Dietary Supplements.
[Link] Updates February 11, 2016. Accessed October 22, 2017.

7.3.16 [Link]
Folate
Folate is a required coenzyme for the synthesis of the amino acid methionine, and for making RNA and DNA. Therefore, rapidly
dividing cells are most affected by folate deficiency. Red blood cells, white blood cells, and platelets are continuously being
synthesized in the bone marrow from dividing stem cells. When folate is deficient, cells cannot divide normally A consequence of
folate deficiency is macrocytic or megaloblastic anemia. Macrocytic and megaloblastic mean “big cell,” and anemia refers to fewer
red blood cells or red blood cells containing less hemoglobin. Macrocytic anemia is characterized by larger and fewer red blood
cells. It is caused by red blood cells being unable to produce DNA and RNA fast enough—cells grow but do not divide, making
them large in size. (Figure )

Figure : Folate and the

Formation of Macrocytic Anemia. Image by Allison Calabrese / CC BY 4.0
Folate is especially essential for the growth and specialization of cells of the central nervous system. Children whose mothers were
folate-deficient during pregnancy have a higher risk of neural-tube birth defects. Folate deficiency is causally linked to the
development of spina bifida, a neural-tube defect that occurs when the spine does not completely enclose the spinal cord. Spina
bifida can lead to many physical and mental disabilities (Figure 9.18 ). Observational studies show that the prevalence of neural-
tube defects was decreased after the fortification of enriched cereal grain products with folate in 1996 in the United States (and
1998 in Canada) compared to before grain products were fortified with folate.
Additionally, results of clinical trials have demonstrated that neural-tube defects are significantly decreased in the offspring of
mothers who began taking folate supplements one month prior to becoming pregnant and throughout the pregnancy. In response to
the scientific evidence, the Food and Nutrition Board of the Institute of Medicine (IOM) raised the RDA for folate to 600
micrograms per day for pregnant women. Some were concerned that higher folate intakes may cause colon cancer, however
scientific studies refute this hypothesis.

7.3.17 [Link]
 Figure :
Spina Bifida in Infants. Spina bifida is a neural-tube defect that can have severe health consequences.

Dietary Reference Intakes

The RDAs and ULs for different age groups for folate are listed in Table 9.25 “Dietary Reference Intakes for Folate “. Folate is a
compound that is found naturally in foods. Folic acid however is the chemical structure form that is used in dietary supplements as
well as enriched foods such as grains. The FNB has developed dietary folate equivalents (DFE) to reflect the fact that folic acid is
more bioavailable and easily absorbed than folate found in food. The conversions for the different forms are listed below.
1 mcg DFE = 1 mcg food folate
1 mcg DFE = 0.6 mcg folic acid from fortified foods or dietary supplements consumed with foods
1 mcg DFE = 0.5 mcg folic acid from dietary supplements taken on an empty stomach
Table : Dietary Reference Intakes for Folate

Age Group RDA Males and Females mcg DFE/day UL

Infants (0–6 months) 65* Not possible to determine

Infants (7–12 months) 80* Not possible to determine

Children (1–3 years) 150 300

Children (4–8 years) 200 400

Children (9–13 years) 300 600

Adolescents (14–18 years) 400 800

Adults (> 19 years) 400 1000

*denotes Adequate Intake

Dietary Supplement Fact Sheet: Folate. National Institute of Health, Office of Dietary Supplements.
[Link] Updated April 20, 2016. Accessed October 22, 2017.

Dietary Sources
Folate is found naturally in a wide variety of food especially in dark leafy vegetables, fruits, and animal products. The U.S. Food
and Drug Administration (FDA) began requiring manufacturers to fortify enriched breads, cereals, flours, and cornmeal to increase
the consumption of folate in the American diet. For the folate content of various foods, see Table 9.26.
Table : Folate Content of Various Foods

7.3.18 [Link]
 Food Serving Folate (mcg DFE) Percent Daily Value

Beef Liver 3 oz. 215 54

Fortified breakfast cereals ¾ c. 400 100

Spinach ½ c. 131 33

White rice, enriched ½ c. 90 23

Asparagus 4 spears 85 20

White bread, enriched 1 slice 43 11

Broccoli 2 spears 45 10

Avocado ½ c. 59 15

Orange juice 6 oz. 35 9

Egg 1 large 22 6

Dietary Supplement Fact Sheet: Folate. National Institute of Health, Office of Dietary Supplements.
[Link] Updated April 20, 2016. Accessed October 22, 2017.

Vitamin B12 (Cobalamin)

Vitamin B12 contains cobalt, making it the only vitamin that contains a metal ion. Vitamin B12 is an essential part of coenzymes. It
is necessary for fat and protein catabolism, for folate coenzyme function, and for hemoglobin synthesis. An enzyme requiring
vitamin B12 is needed by a folate-dependent enzyme to synthesize DNA. Thus, a deficiency in vitamin B12 has similar
consequences to health as folate deficiency. In children and adults vitamin B12 deficiency causes macrocytic anemia, and in babies
born to cobalamin-deficient mothers there is an increased risk for neural-tube defects. In order for the human body to absorb
vitamin B12, the stomach, pancreas, and small intestine must be functioning properly. Cells in the stomach secrete a protein called
intrinsic factor that is necessary for vitamin B12 absorption, which occurs in the small intestine. Impairment of secretion of this
protein either caused by an autoimmune disease or by chronic inflammation of the stomach (such as that occurring in some people
with [Link] infection), can lead to the disease pernicious anemia, a type of macrocytic anemia. Vitamin B12 malabsorption is
most common in the elderly, who may have impaired functioning of digestive organs, a normal consequence of aging. Pernicious
anemia is treated by large oral doses of vitamin B12 or by putting the vitamin under the tongue, where it is absorbed into the
bloodstream without passing through the intestine. In patients that do not respond to oral or sublingual treatment vitamin B12 is
given by injection.

7.3.19 [Link]
Vitamin B12 Relationship with Folate and Vitamin B6

Figure : B Vitamins Coenzyme Roles.

Image by Allison Calabrese / CC BY 4.0
Vitamin B12 and folate play key roles in converting homocysteine to amino acid methionine. As mentioned in Figure 9.19, high
levels of homocysteine in the blood increases the risk for heart disease. Low levels of vitamin B12, folate or vitamin B6 will
increase homocysteine levels therefore increasing the risk of heart disease.

Figure : The Relationship Between

Folate and Vitamin B12. Image by Allison Calabrese / CC BY 4.0
When there is a deficiency in vitamin B12 , inactive folate (from food) is unable to be converted to active folate and used in the
body for the synthesis of DNA. Folic Acid however (that comes from supplements or fortified foods) is available to be used as
active folate in the body without vitamin B12 .Therefore, if there is a deficiency in vitamin B12 macrocytic anemia may occur. With
the fortification of foods incorporated into people’s diets, the risk of an individual developing macrocytic anemia is decreased.

7.3.20 [Link]
Dietary Reference Intakes
The RDAs and ULs for different age groups for Vitamin B12 are listed in Table .
Table : Dietary Reference Intakes for Vitamin B12
Age Group RDA Males and Females mcg/day

Infants (0–6 months) 0.4*

Infants (7–12 months) 0.5*

Children (1–3 years) 0.9

Children (4–8 years) 1.2

Children (9–13 years) 1.8

Adolescents (14–18 years) 2.4

Adults (> 19 years) 2.4

*denotes Adequate Intake

Dietary Fact Sheet: Vitamin B12. National Institute of Health, Office of Dietary Supplements.
[Link] Updated February 11, 2016. Accessed October 28, 2017.

Dietary Sources
Vitamin B12 is found naturally in animal products such as fish, meat, poultry, eggs, and milk products. Although vitamin B12 is not
generally present in plant foods, fortified breakfast cereals are also a good source of vitamin B12. For the vitamin B12 content of
various foods, see Table .
Table : Vitamin B12 Content of Various Foods

Food Serving Vitamin B12 (mcg) Percent Daily Value

Clams 3 oz. 84.1 1,402

Salmon 3 oz. 4.8 80

Tuna, canned 3 oz. 2.5 42

Breakfast cereals, fortified 1 serving 1.5 25

Beef, top sirloin 3 oz. 1.4 23

Milk, lowfat 8 fl oz. 1.2 18

Yogurt, lowfat 8 oz. 1.1 18

Cheese, swiss 1 oz. 0.9 15

Egg 1 large 0.6 10

Dietary Fact Sheet: Vitamin B12. National Institute of Health, Office of Dietary Supplements.
[Link] Updated February 11, 2016. Accessed October 28, 2017.

Choline
Choline is a water-soluble substance that is not classified as a vitamin because it can be synthesized by the body. However, the
synthesis of choline is limited and therefore it is recognized as an essential nutrient. Choline is need to perform functions such as
the synthesis of neurotransmitter acetylcholine, the synthesis of phospholipids used to make cell membranes, lipid transport, and

7.3.21 [Link]
also homocysteine metabolism. A deficiency in choline may lead to interfered brain development in the fetus during pregnancy, and
in adults cause fatty liver and muscle damage.

Dietary Reference Intakes

There is insufficient data on choline so the FNB has developed AIs for all ages in order to prevent fatty liver disease. The AI and
UL for different age groups for choline are listed in Table .
Table : Dietary Reference Intakes for Choline
Age Group AI Males and Females mg/day) UL

Infants (0–6 months) 125 –

Infants (7–12 months) 150 –

Children (1–3 years) 200 1000

Children (4–8 years) 250 1000

Children (9–13 years) 375 2000

Adolescents (14–18 years) 550 (males), 400 (females) 3000

Adults (> 19 years) 550 (males), 425 (females) 3500

Fact Sheet for Health Professionals: Choline. National Institute of Health, Office of Dietary Supplements.
[Link] Updated January 25, 2017. Accessed October 28, 2017.

Dietary Sources
Choline can be found in a variety of different foods. The main dietary sources of choline in the United States consist of primarily
animal based products. For the Choline content of various foods, see Table .
Table : Choline Content of Various Foods
Food Serving Choline (mg) Percent Daily Value

Egg 1 large 147 27

Soybeans ½ cup 107 19

Chicken breast 3 oz. 72 13

Mushrooms, shiitake ½ c. 58 11

Potatoes 1 large 57 10

Kidney beans ½ c. 45 8

Peanuts ¼ c. 24 4

Brown rice 1 c. 19 3

Fact Sheet for Health Professionals: Choline. National Institute of Health, Office of Dietary Supplements.
[Link] Updated January 25, 2017. Accessed October 28, 2017.

Summary of Water-Soluble Vitamins

Table : Water-Soluble vitamins

7.3.22 [Link]
 Recommended Deficiency
Major Groups at risk
Vitamin Sources Intake for diseases and Toxicity UL
Functions of deficiency
adults symptoms

Orange juice, Antioxidant, Scurvy,

grapefruit collagen bleeding
Smokers, Kidney stones,
Vitamin C juice, synthesis, gums, joint
75-90 mg/day alcoholics, GI distress, 2000 mg/day
(ascorbic acid) strawberries, hormone and pain, poor
elderly diarrhea
tomato, sweet neurotransmitt wound
red pepper er synthesis healing,

Coenzyme: Beriberi:
assists in fatigue,
Pork, enriched Alcoholics,
glucose confusion,
and whole 1.1-1.2 older adults,
Thiamin (B1) metabolism, movement None reported ND
grains, fish, mg/day eating
RNA, DNA, impairment,
legumes disorders
and ATP swelling, heart
synthesis failure

Coenzyme:
assists in Ariboflavinosi
Beef liver,
glucose, fat s: dry scaly
enriched
and skin, mouth
breakfast
Riboflavin 1.1-1.3 carbohydrate inflammation
cereals, None None reported ND
(B2) mg/day metabolism, and sores, sore
yogurt, steak,
electron throat, itchy
mushrooms,
carrier, other eyes, light
almonds, eggs
B vitamins are sensitivity
dependent on

Coenzyme:
assists in Pellagra:
Meat, poultry, 35 mg/day
glucose, fat, diarrhea, Nausea, rash,
fish, peanuts, from fortified
Niacin (B3) 14-16 NE/day and protein dermatitis, Alcoholics tingling
enriched foods and
metabolism, dementia, extremities
grains supplements
electron death
carrier

Coenzyme:
assists in
Sunflower
glucose, fat,
seeds, fish, Muscle
and protein
Pantothenic dairy numbness and
5 mg/day metabolism, Alcoholics Fatigue, rash ND
Acid (B5) products, pain, fatigue,
cholesterol
widespread in irritability
and
foods
neurotransmitt
er synthesis

B6(Pyridoxine Meat, poultry, 1.3-1.7 Coenzyme; Muscle Alcoholics Nerve damage 100 mg/day
) fish, legumes, mg/day assists in weakness,
nuts amino-acid dermatitis,
synthesis, mouth sores,
glycogneolysi fatigue,
s, confusion
neurotransmitt

7.3.23 [Link]
 Recommended Deficiency
Major Groups at risk
Vitamin Sources Intake for diseases and Toxicity UL
Functions of deficiency
adults symptoms
er and
hemoglobin
synthesis

Coenzyme;
assists in Muscle
Those
Egg yolks, glucose, fat, weakness,
consuming
Biotin fish, pork, 30 mcg/day and protein dermatitis, None reported ND
raw egg
nuts and seeds metabolism, fatigue, hair
whites
amino-acid loss
synthesis

Coenzyme; Diarrhea,
Leafy green
amino acid mouth sores, 1000 mcg/day
vegetables, Pregnant
synthesis, confusion, Masks B12 from fortified
Folate enriched 400 mcg/day women,
RNA, DNA, anemia, deficiency foods and
grains, orange alcoholics
and red blood neural-tube supplements
juice
cell synthesis defects

Coenzyme; fat Muscle

and protein weakness,
catabolism, sore tongue,
B12(cobalami Meats, Vegans,
2.4 mcg/day folate anemia, nerve None reported ND
n) poultry, fish elderly
function, red- damage,
blood-cell neural-tube
synthesis defects

Non-alcoholic
fatty liver
Synthesis of disease,
Egg yolk, Liver damage,
neurotransmitt muscle
wheat, meat, 425-550 excessive
Choline ers and cell damage, None 3500 mg/day
fish, synthesis mg/day sweating,
membranes, interfered
in the body hypotension
lipid transport brain
development
in fetus

Do B-Vitamin Supplements Provide an Energy Boost?

Although some marketers claim taking a vitamin that contains one-thousand times the daily value of certain B vitamins boosts
energy and performance, this is a myth that is not backed by science. The “feeling” of more energy from energy-boosting
supplements stems from the high amount of added sugars, caffeine, and other herbal stimulants that accompany the high doses of B
vitamins. As discussed, B vitamins are needed to support energy metabolism and growth, but taking in more than required does not
supply you with more energy. A great analogy of this phenomenon is the gas in your car. Does it drive faster with a half-tank of gas
or a full one? It does not matter; the car drives just as fast as long as it has gas. Similarly, depletion of B vitamins will cause
problems in energy metabolism, but having more than is required to run metabolism does not speed it up. Buyers of B-vitamin
supplements beware; B vitamins are not stored in the body and all excess will be flushed down the toilet along with the extra
money spent.
B vitamins are naturally present in numerous foods, and many other foods are enriched with them. In the United States, B-vitamin
deficiencies are rare; however in the nineteenth century some vitamin-B deficiencies plagued many people in North America.

7.3.24 [Link]
Niacin deficiency, also known as pellagra, was prominent in poorer Americans whose main dietary staple was refined cornmeal. Its
symptoms were severe and included diarrhea, dermatitis, dementia, and even death. Some of the health consequences of pellagra
are the result of niacin being in insufficient supply to support the body’s metabolic functions.

Resources
1. Mente A, et al. (2009). A Systematic Review of the Evidence Supporting a Causal Link between Dietary Factors and Coronary
Heart Disease. Archives of Internal Medicine, 169(7), 659–69. [Link] Accessed
October 5, 2017. ↵
2. Myint PK, et al. (2008). Plasma Vitamin C Concentrations Predict Risk of Incident Stroke Over 10 Years in 20,649 Participants
of the European Prospective Investigation into Cancer, Norfolk Prospective Population Study. American Journal of Clinical
Nutrition, 87(1), 64–69. [Link]/content/87/1/[Link]. Accessed September 22, 2017. ↵
3. Douglas RM, et al. (2004). Vitamin C for Preventing and Treating the Common Cold. Cochrane Database of Systematic
Reviews, 4. [Link] Accessed October 5, 2017. ↵
4. Frederick Gowland Hopkins and his Accessory Food Factors. Encyclopedia Brittanica Blog.
[Link]/blogs/2011/06/frederick-gowland-hopkins-accessory-food-factors/.Published June 20, 2011. Accessed
October 1, 2011. ↵
5. Fact Sheets for Health Professionals: Thiamin. National Institute of Health, Office of Dietary Supplements.
[Link] Updated Feburary 11, 2016. Accessed October 22, 2017. ↵

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Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts
platform.
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Original source: [Link]

7.3.25 [Link]
7.4: Antioxidants
The market is flooded with advertisements for “super antioxidant” supplements teeming with molecules that block free radical
production, stimulate the immune system, prevent cancer, and reduce the signs of aging. Based on the antioxidant-supplement
industry’s success, the general public appears to believe these health claims. However, these claims are not backed by scientific
evidence; rather, there is some evidence suggesting supplements can actually cause harm. While scientists have found evidence
supporting the consumption of antioxidant-rich foods as a method of reducing the risk of chronic disease, there is no “miracle
cure”; no pill or supplement alone can provide the same benefits as a healthy diet. Remember, it is the combination of antioxidants
and other nutrients in healthy foods that is beneficial. In this section, we will review how particular antioxidants function in the
body, learn how they work together to protect the body against free radicals, and explore the best nutrient-rich dietary sources of
antioxidants. One dietary source of antioxidants is vitamins. In our discussion of antioxidant vitamins, we will focus on vitamins E,
C, and A.

Figure : Antioxidants’ Role. Image by Allison Calabrese / CC

BY 4.0

Antioxidant Chemicals Obtained from the Diet

There are many different antioxidants in food, including selenium, which is one of the major antioxidants. However, the
antioxidants you may be the most familiar with are vitamins. The “big three” vitamin antioxidants are vitamins E, A, and C,
although it may be that they are called the “big three” only because they are the most studied.
Table : Some Antioxidants Obtained from Diet and Their Related Functions

Antioxidant Antioxidant Source Antioxidant Function

Protects cellular membranes, prevents

glutathione depletion, maintains free radical
Vitamin A Karat banana, beef liver, chicken liver
detoxifying enzyme systems, reduces
inflammation
Protects cellular membranes, prevents
Vitamin E Sunflower seeds, almonds, sunflower oil
glutathione depletion

Protects DNA, RNA, proteins, and lipids,

Vitamin C Oranges, grapefruit
aids in regenerating vitamin E

Swordfish, salmon, tuna fish canned in Regulates blood calcium levels in concert
Vitamin D
water and drained with parathyroid hormone

Carotenoids Pumpkin, carrots Free radical scavenger

7.4.1 [Link]
This page titled 7.4: Antioxidants is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper,
Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.
9.4: Antioxidants by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original source:
[Link]

7.4.2 [Link]
7.5: The Body’s Offense
While our bodies have acquired multiple defenses against free radicals, we also use free radicals to support its functions. For
example, the immune system uses the cell-damaging properties of free radicals to kill pathogens. First, immune cells engulf an
invader (such as a bacterium), then they expose it to free radicals such as hydrogen peroxide, which destroys its membrane. The
invader is thus neutralized. Scientific studies also suggest hydrogen peroxide acts as a signaling molecule that calls immune cells to
injury sites, meaning free radicals may aid with tissue repair when you get cut.
Free radicals are necessary for many other bodily functions as well. The thyroid gland synthesizes its own hydrogen peroxide,
which is required for the production of thyroid hormone. Reactive oxygen species and reactive nitrogen species, which are free
radicals containing nitrogen, have been found to interact with proteins in cells to produce signaling molecules. The free radical
nitric oxide has been found to help dilate blood vessels and act as a chemical messenger in the brain. By acting as signaling
molecules, free radicals are involved in the control of their own synthesis, stress responses, regulation of cell growth and death, and
metabolism.

Sources of Free Radicals in the Environment

Substances and energy sources from the environment can add to or accelerate the production of free radicals within the body.
Exposure to excessive sunlight, ozone, smoke, heavy metals, ionizing radiation, asbestos, and other toxic chemicals increase the
amount of free radicals in the body. They do so by being free radicals themselves or by adding energy that provokes electrons to
move between atoms. Excessive exposure to environmental sources of free radicals can contribute to disease by overwhelming the
free radical detoxifying systems and those processes involved in repairing oxidative damage.

Oxidative Stress
Oxidative stress refers to an imbalance in any cell, tissue, or organ between the amount of free radicals and the capabilities of the
detoxifying and repair systems. Sustained oxidative damage results only under conditions of oxidative stress—when the
detoxifying and repair systems are insufficient. Free radical-induced damage, when left unrepaired, destroys lipids, proteins, RNA,
and DNA, and can contribute to disease. Oxidative stress has been implicated as a contributing factor to cancer, atherosclerosis
(hardening of arteries), arthritis, diabetes, kidney disease, Alzheimer’s disease, Parkinson’s disease, schizophrenia, bipolar disorder,
emphysema, and cataracts.
Aging is a process that is genetically determined but modulated by factors in the environment. In the process of aging, tissue
function declines. The idea that oxidative stress is the primary contributor to age-related tissue decline has been around for decades,
and it is true that tissues accumulate free radical-induced damage as we age. Recent scientific evidence slightly modifies this theory
by suggesting oxidative stress is not the initial trigger for age-related decline of tissues; it is suggested that the true culprit is
progressive dysfunction of metabolic processes, which leads to increases in free radical production, thus influencing the stress
response of tissues as they age.

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Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts
platform.
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source: [Link]

7.5.1 [Link]
7.6: Phytochemicals
Phytochemicals are chemicals in plants that may provide some health benefit. Carotenoids are one type of phytochemical.
Phytochemicals also include indoles, lignans, phytoestrogens, stanols, saponins, terpenes, flavonoids, carotenoids, anthocyanidins,
phenolic acids, and many more. They are found not only in fruits and vegetables, but also in grains, seeds, nuts, and legumes.
Many phytochemicals act as antioxidants, but they have several other functions, such as mimicking hormones, altering absorption
of cholesterol, inhibiting inflammatory responses, and blocking the actions of certain enzymes.
Phytochemicals are present in small amounts in the food supply, and although thousands have been and are currently being
scientifically studied, their health benefits remain largely unknown. Also largely unknown is their potential for toxicity, which
could be substantial if taken in large amounts in the form of supplements. Moreover, phytochemicals often act in conjunction with
each other and with micronutrients. Thus, supplementing with only a few may impair the functions of other phytochemicals or
micronutrients. As with the antioxidant vitamins, it is the mixture and variety of phytochemicals in foods that are linked to health
benefits.
Table : Some Phytochemical’s Obtained from Diet and Their Related Functions

Phytochemical Phytochemical Source Phytochemical Function:

Yellow-orange fruits, dark green leafy May possess strong cancer-fighting

Carotenoid
vegetables properties

May inhibit the development of cancer-

Cruciferous vegetables (i.e. bok choy,
Indoles causing hormones and prevent tumor
broccoli, choy sum)
growth
May lower the risk for osteoporosis, heart
Grapes, berries, plums, soybeans, tofu,
Phytoestrogen disease, breast cancer, and menopausal
garlic
symptoms
May lower blood cholesterol levels and
Stanols Grains, nuts, legumes
reduce the risk of heart disease and stroke

May decrease blood lipids, lower cancer

Saponins Broad beans, kidney beans, lentils
risks, and lower blood glucose response
May slow cancer cell growth, aid in
Terpenes Citrus fruits immune system support, and prevent virus
related illness

Fruits, vegetables, chocolates, wines, teas, May benefit the immune system and
Flavonoids
nuts, seeds prevent cancer cell growth.

May prevent cardiovascular disease, reduce

Fruits and vegetables with vibrant colors of cancer cell proliferation
Anthocyanidins
orange, red, purple, and blue (growth/multiplication) and inhibit tumor
formation.
May prevent cellular damage due to free-
Coffee, fruits, vegetables, nuts, cereals,
Phenolic acids radical oxidation reaction and promote anti-
legumes, oilseeds, beverages and herbs
inflammatory conditions in the body.

Resources
1. Bacciottini, L., Falchetti, A., Pampaloni, B., Bartolini, E., Carossino, A. M., & Brandi, M. L. (2007). Phytoestrogens: Food or
drug? Clinical Cases in Mineral and Bone Metabolism, 4(2), 123–130.
1. Bagchi, D., Sen, C. K., Bagchi, M., & Atalay, M. (2004). Anti-angiogenic, antioxidant, and anti-carcinogenic properties of a
novel anthocyanin-rich berry extract formula. Biochemistry. Biokhimiia, 69(1), 75–80, 1 p preceding 75.

7.6.1 [Link]
 [Link]
1. Flavonoids. (2014, April 28). Linus Pauling Institute. [Link]
1. Goto, T., Takahashi, N., Hirai, S., & Kawada, T. (2010). Various Terpenoids Derived from Herbal and Dietary Plants Function
as PPAR Modulators and Regulate Carbohydrate and Lipid Metabolism. PPAR Research, 2010.
[Link]
1. Higdon, J. V., Delage, B., Williams, D. E., & Dashwood, R. H. (2007). Cruciferous Vegetables and Human Cancer Risk:
Epidemiologic Evidence and Mechanistic Basis. Pharmacological Research : The Official Journal of the Italian
Pharmacological Society, 55(3), 224–236. [Link]
1. Kozłowska, A., & Szostak-Wegierek, D. (2014). Flavonoids—Food sources and health benefits. Roczniki Panstwowego
Zakladu Higieny, 65(2), 79–85.
2. Patisaul, H. B., & Jefferson, W. (2010). The pros and cons of phytoestrogens. Frontiers in Neuroendocrinology, 31(4), 400–419.
[Link]
3. Phenolic Acids—An overview | ScienceDirect Topics. (n.d.). Retrieved June 29, 2020, from www-sciencedirect-
[Link]/topics/food-science/phenolic-acids
4. Phytochemicals—[Link]. (n.d.). Retrieved June 9, 2020, from
[Link]
5. Shi, J., Arunasalam, K., Yeung, D., Kakuda, Y., Mittal, G., & Jiang, Y. (2004). Saponins from Edible Legumes: Chemistry,
Processing, and Health Benefits. Journal of Medicinal Food, 7(1), 67–78. [Link]
6. Thompson, G. R., & Grundy, S. M. (2005). History and Development of Plant Sterol and Stanol Esters for Cholesterol-
Lowering Purposes. The American Journal of Cardiology, 96(1, Supplement), 3–9.
[Link]
7. Xu, D.-P., Li, Y., Meng, X., Zhou, T., Zhou, Y., Zheng, J., Zhang, J.-J., & Li, H.-B. (2017). Natural Antioxidants in Foods and
Medicinal Plants: Extraction, Assessment and Resources. International Journal of Molecular Sciences, 18(1).
[Link]
8. Yousuf, B., Gul, K., Wani, A. A., & Singh, P. (2016). Health Benefits of Anthocyanins and Their Encapsulation for Potential
Use in Food Systems: A Review. Critical Reviews in Food Science and Nutrition, 56(13), 2223–2230.
[Link]
9. Zamora-Ros, R., Rothwell, J. A., Scalbert, A., Knaze, V., Romieu, I., Slimani, N., Fagherazzi, G., Perquier, F., Touillaud, M.,
Molina-Montes, E., Huerta, J. M., Barricarte, A., Amiano, P., Menéndez, V., Tumino, R., de Magistris, M. S., Palli, D., Ricceri,
F., Sieri, S., … González, C. A. (2013). Dietary intakes and food sources of phenolic acids in the European Prospective
Investigation into Cancer and Nutrition (EPIC) study. The British Journal of Nutrition, 110(8), 1500–1511.
[Link]

This page titled 7.6: Phytochemicals is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper,
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[Link]

7.6.2 [Link]
 CHAPTER OVERVIEW

8: Water and Electrolytes

Learning Objectives
By the end of this chapter you will be able to:
Describe the importance of water intake for the body
Describe the major aspects of water regulation in the body
Describe the function, balance, sources, and consequences of the imbalance of [electrolytes
Describe the effects and use of popular beverage choices

8.1: Introduction to Water and Electrolytes

8.2: Overview of Fluid and Electrolyte Balance
8.3: Water’s Importance to Vitality
8.4: Regulation of Water Balance
8.5: Electrolytes Important for Fluid Balance
8.6: Sodium
8.7: Chloride
8.8: Potassium
8.9: Consequences of Deficiency or Excess
8.10: Water Concerns
8.11: Popular Beverage Choices

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1
8.1: Introduction to Water and Electrolytes
Ola i ka wai a ka ‘ōpua
There is life in the water from the clouds

Figure : Image by Cassie Matias on [Link] / CC0

Maintaining the right level of water in your body is crucial to survival, as either too little or too much water in your body will result
in less-than-optimal functioning. One mechanism to help ensure the body maintains water balance is thirst. Thirst is the result of
your body’s physiology telling your brain to initiate the thought to take a drink. Sensory proteins detect when your mouth is dry,
your blood volume too low, or blood electrolyte concentrations too high and send signals to the brain stimulating the conscious
feeling to drink.
In the summer of 1965, the assistant football coach of the University of Florida Gators requested scientists affiliated with the
university study why the withering heat of Florida caused so many heat-related illnesses in football players and provide a solution
to increase athletic performance and recovery post-training or game. The discovery was that inadequate replenishment of fluids,
carbohydrates, and electrolytes was the reason for the “wilting” of their football players. Based on their research, the scientists
concocted a drink for the football players containing water, carbohydrates, and electrolytes and called it “Gatorade.” In the next
football season the Gators were nine and two and won the Orange Bowl. The Gators’ success launched the sports-drink industry,
which is now a multibillion-dollar industry that is still dominated by Gatorade.
The latest National Health and Nutrition Examination Survey, covering the period from 2005 to 2008, reports that about 50 percent
of Americans consume sugary drinks daily.[1]
Excess consumption of sugary soft drinks have been scientifically proven to increase the risk for dental caries, obesity, Type 2
diabetes, and cardiovascular disease. In addition to sugary soft drinks, beverages containing added sugars include fruit drinks,
sports drinks, energy drinks and sweetened bottled waters.
Sports drinks are designed to rehydrate the body after excessive fluid depletion. Electrolytes in particular promote normal
rehydration to prevent fatigue during physical exertion. Are they a good choice for achieving the recommended fluid intake? Are
they performance and endurance enhancers like they claim? Who should drink them?
Typically, eight ounces of a sports drink provides between fifty and eighty calories and 14 to 17 grams of carbohydrate, mostly in
the form of simple sugars. Sodium and potassium are the most commonly included electrolytes in sports drinks, with the levels of
these in sports drinks being highly variable. The American College of Sports Medicine says a sports drink should contain 125
milligrams of sodium per 8 ounces as it is helpful in replenishing some of the sodium lost in sweat and promotes fluid uptake in the
small intestine, improving hydration.

8.1.1 [Link]
In this chapter we will discuss the importance and functions of fluid and electrolyte balance in the human body, the consequences
of getting too much or too little of water and electrolytes, the best dietary sources of these nutrients, and healthier beverage choices.
After reading this chapter you will know what to look for in sports drinks and will be able to select the best products to keep
hydrated.
1. Ogden C, Kit B, et al. (2011). Consumption of Sugar Drinks in the United States, 2005–2008. Centers for Disease Control and
Prevention. NCHS Data Brief no. 71. [Link] Published August 2011. Accessed
September 22, 2017. ↵

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8.1.2 [Link]
8.2: Overview of Fluid and Electrolyte Balance
Water is made up of 2 hydrogen atoms and 1 oxygen atom (Figure 3.1). A human body is made up of mostly water. An adult
consists of about 37 to 42 liters of water, or about eighty pounds. Fortunately, humans have compartmentalized tissues; otherwise
we might just look like a water balloon! Newborns are approximately 70 percent water. Adult males typically are composed of
about 60 percent water and females are about 55 percent water. (This gender difference reflects the differences in body-fat content,
since body fat is practically water-free. This also means that if a person gains weight in the form of fat the percentage of total body
water content declines.) As we age, total body water content also diminishes so that by the time we are in our eighties the percent of
water in our bodies has decreased to around 45 percent. Does the loss in body water play a role in the aging process? Alas, no one
knows. But, we do know that dehydration accelerates the aging process whereas keeping hydrated decreases headaches, muscle
aches, and kidney stones. Additionally a study conducted at the Fred Hutchinson Cancer Research Center in Seattle found that
women who drank more than five glasses of water each day had a significantly decreased risk for developing colon cancer.[1]

Figure : The Water Molecule. “Water Molecule” by Chris Martin / Public Domain

Fluid and Electrolyte Balance

Although water makes up the largest percentage of body volume, it is not actually pure water but rather a mixture of cells, proteins,
glucose, lipoproteins, electrolytes, and other substances. Electrolytes are substances that, when dissolved in water, dissociate into
charged ions. Positively charged electrolytes are called cations and negatively charged electrolytes are called anions. For example,
in water sodium chloride (the chemical name for table salt) dissociates into sodium cations ( ) and chloride anions ( ). Solutes
refers to all dissolved substances in a fluid, which may be charged, such as sodium ( ), or uncharged, such as glucose. In the
human body, water and solutes are distributed into two compartments: inside cells, called intracellular, and outside cells, called
extracellular. The extracellular water compartment is subdivided into the spaces between cells also known as interstitial, blood
plasma, and other bodily fluids such as the cerebrospinal fluid which surrounds and protects the brain and spinal cord (Figure
). The composition of solutes differs between the fluid compartments. For instance, more protein is inside cells than outside
and more chloride anions exist outside of cells than inside.

Figure : Distribution of Body Water. Image by Allison

Calabrese / CC BY 4.0

8.2.1 [Link]
Osmoregulation
One of the essential homeostatic functions of the body is to maintain fluid balance and the differences in solute composition
between cells and their surrounding environment. Osmoregulation is the control of fluid balance and composition in the body. The
processes involved keep fluids from becoming too dilute or too concentrated. Fluid compartments are separated by selectively
permeable membranes, which allow some things, such as water, to move through while other substances require special transport
proteins, channels, and often energy. The movement of water between fluid compartments happens by osmosis, which is simply the
movement of water through a selectively permeable membrane from an area where it is highly concentrated to an area where it is
not so concentrated. Water is never transported actively; that is, it never takes energy for water to move between compartments.
Although cells do not directly control water movement, they do control movement of electrolytes and other solutes and thus
indirectly regulate water movement by controlling where there will be regions of high and low concentrations.
Cells maintain their water volume at a constant level, but the composition of solutes in a cell is in a continuous state of flux. This is
because cells are bringing nutrients in, metabolizing them, and disposing of waste products. To maintain water balance a cell
controls the movement of electrolytes to keep the total number of dissolved particles, called osmolality the same inside and outside
(Figure ). The total number of dissolved substances is the same inside and outside a cell, but the composition of the fluids
differs between compartments. For example, sodium exists in extracellular fluid at fourteen times the concentration as compared to
that inside a cell.

Figure : Osmoregulation. “Osmosis” by

Mariana Ruiz / Public Domain
Cells maintain water volume by actively controlling electrolyte concentrations. Human erythrocytes (red blood cells) are shown
here. Three conditions are shown: hypertonic conditions (where the erythrocytes contract and appear “spiky”), isotonic conditions
(where the erythrocytes appear normal) and hypotonic conditions (where the etrythrocytes expand and become more round).
If a cell is placed in a solution that contains fewer dissolved particles (hypotonic solution) than the cell itself, water moves into the
more concentrated cell, causing it to swell. Alternatively, if a cell is placed in a solution that is more concentrated (known as a
hypertonic solution) water moves from inside the cell to the outside, causing it to shrink. Cells keep their water volume constant by
pumping electrolytes in and out in an effort to balance the concentrations of dissolved particles on either side of their membranes.
When a solution contains an equal concentration of dissolved particles on either side of the membrane, it is known as an isotonic
solution.

Resources
1. Shannon JE, et al. (1996). Relationship of Food Groups and Water Intake to Colon Cancer Risk. Cancer, Epidemiology,
Biomarkers & Prevention, 5(7), 495–502. [Link] Accessed September 22, 2017. ↵

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8.2.2 [Link]
8.2.3 [Link]
8.3: Water’s Importance to Vitality
You get up in the morning, flush wastes down the toilet, take a shower, brush your teeth, drink, eat, drive, wash the grime from
your windshield, get to work, and drink coffee. Next to a fountain you eat lunch and down it with a glass of water, you use the toilet
again and again, drive home, prepare dinner, etc. Add all the ways you use water every day and you still will not come close to the
countless uses water has in the human body. Of all the nutrients, water is the most critical as its absence proves lethal within a few
days. Organisms have adapted numerous mechanisms for water conservation. Water uses in the human body can be loosely
categorized into four basic functions: transportation vehicle, medium for chemical reactions, lubricant/shock absorber, and
temperature regulator.

Figure : Image by NASA on [Link] / CC0

Water is the foundation of all life—the surface of the earth is 70 percent water; the volume of water in humans is about 60 percent.

Water As a Transportation Vehicle

Water is called the “universal solvent” because more substances dissolve in it than any other fluid. Molecules dissolve in water
because of the hydrogen and oxygen molecules ability to loosely bond with other molecules. Molecules of water (H2O) surround
substances, suspending them in a sea of water molecules. The solvent action of water allows for substances to be more readily
transported. A pile of undissolved salt would be difficult to move throughout tissues, as would a bubble of gas or a glob of fat.
Blood, the primary transport fluid in the body is about 78 percent water. Dissolved substances in blood include proteins,
lipoproteins, glucose, electrolytes, and metabolic waste products, such as carbon dioxide and urea. These substances are either
dissolved in the watery surrounding of blood to be transported to cells to support basic functions or are removed from cells to
prevent waste build-up and toxicity. Blood is not just the primary vehicle of transport in the body, but also as a fluid tissue blood
structurally supports blood vessels that would collapse in its absence. For example, the brain which consists of 75 percent water is
used to provide structure.

Water As a Medium for Chemical Reactions

Water is required for even the most basic chemical reactions. Proteins fold into their functional shape based on how their amino-
acid sequences react with water. These newly formed enzymes must conduct their specific chemical reactions in a medium, which
in all organisms is water. Water is an ideal medium for chemical reactions as it can store a large amount of heat, is electrically
neutral, and has a pH of 7.0, meaning it is not acidic or basic. Additionally, water is involved in many enzymatic reactions as an
agent to break bonds or, by its removal from a molecule, to form bonds.

8.3.1 [Link]
Water As a Lubricant/Shock Absorber
Many may view the slimy products of a sneeze as gross, but sneezing is essential for removing irritants and could not take place
without water. Mucus, which is not only essential to discharge nasal irritants, is also required for breathing, transportation of
nutrients along the gastrointestinal tract, and elimination of waste materials through the rectum. Mucus is composed of more than
90 percent water and a front-line defense against injury and foreign invaders. It protects tissues from irritants, entraps pathogens,
and contains immune-system cells that destroy pathogens. Water is also the main component of the lubricating fluid between joints
and eases the movement of articulated bones.
The aqueous and vitreous humors, which are fluids that fill the extra space in the eyes and the cerebrospinal fluid surrounding the
brain and spinal cord, are primarily water and buffer these organs against sudden changes in the environment. Watery fluids
surrounding organs provide both chemical and mechanical protection. Just two weeks after fertilization water fills the amniotic sac
in a pregnant woman providing a cushion of protection for the developing embryo.

Water As a Temperature Regulator

Another homeostatic function of the body, termed thermoregulation is to balance heat gain with heat loss and body water plays an
important role in accomplishing this. Human life is supported within a narrow range of temperature, with the temperature set point
of the body being 98.6°F (37°C). Too low or too high of a temperature causes enzymes to stop functioning and metabolism is
halted. At 82.4°F (28°C) muscle failure occurs and hypothermia sets in. At the opposite extreme of 111.2°F (44°C) the central
nervous system fails and death results. Water is good at storing heat, an attribute referred to as heat capacity and thus helps
maintain the temperature set point of the body despite changes in the surrounding environment.
There are several mechanisms in place that move body water from place to place as a method to distribute heat in the body and
equalize body temperature (Figure ). The hypothalamus in the brain is the thermoregulatory center. The hypothalamus contains
special protein sensors that detect blood temperature. The skin also contains temperature sensors that respond quickly to changes in
immediate surroundings. In response to cold sensors in the skin, a neural signal is sent to the hypothalamus, which then sends a
signal to smooth muscle tissue surrounding blood vessels causing them to constrict and reduce blood flow. This reduces heat lost to
the environment. The hypothalamus also sends signals to muscles to erect hairs and shiver and to endocrine glands like the thyroid
to secrete hormones capable of ramping up metabolism. These actions increase heat conservation and stimulate its production in
the body in response to cooling temperatures.

8.3.2 [Link]
 Figure : Thermoregulatory Center.
Thermoregulation is the ability of an organism to maintain body temperature despite changing environmental temperatures.

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8.3.3 [Link]
8.4: Regulation of Water Balance
As you eat a bite of food, the salivary glands secrete saliva. As the food enters your stomach, gastric juice is secreted. As it enters
the small intestine, pancreatic juice is secreted. Each of these fluids contains a great deal of water. How is that water replaced in
these organs? What happens to the water now in the intestines? In a day, there is an exchange of about 10 liters of water among the
body’s organs. The osmoregulation of this exchange involves complex communication between the brain, kidneys, and endocrine
system. A homeostatic goal for a cell, a tissue, an organ, and an entire organism is to balance water output with water input.

Regulation of Daily Water Input

Total water output per day averages 2.5 liters. This must be balanced with water input. Our tissues produce around 300 milliliters of
water per day through metabolic processes. The remainder of water output must be balanced by drinking fluids and eating solid
foods. The average fluid consumption per day is 1.5 liters, and water gained from solid foods approximates 700 milliliters.

Figure : Daily Fluid Loss and Gain. CO2 + H20 +

ATP); sources of water loss: Skin and lungs (insensible water loss 0.9 L/day), Urine 1.5 L/day, Feces 0.1 L/day. TOTAL intake 2.2
L/day + Metabolic Production 0.3 L/day – Output (0.9+1.5=0.1) L/day = 0 ” class=”wp-image-141 size-full” width=”629″
height=”777″> Daily Fluid Loss and Gain

Dietary Recommendations
The Food and Nutrition Board of the Institute of Medicine (IOM) has set the Adequate Intake (AI) for water for adult males at 3.7
liters (15.6 cups) and at 2.7 liters (11 cups) for adult females.[1] These intakes are higher than the average intake of 2.2 liters. It is
important to note that the AI for water includes water from all dietary sources; that is, water coming from food as well as
beverages. People are not expected to consume 15.6 or 11 cups of pure water per day. In America, approximately 20 percent of
dietary water comes from solid foods. See Table for the range of water contents for selected food items. Beverages includes
water, tea, coffee, sodas, and juices.

8.4.1 [Link]
 Table : Water Content in Foods

Percentage Food Item

Nonfat milk, cantaloupe, strawberries, watermelon, lettuce,

90–99
cabbage, celery, spinach, squash
Fruit juice, yogurt, apples, grapes, oranges, carrots, broccoli, pears,
80–89
pineapple

Bananas, avocados, cottage cheese, ricotta cheese, baked potato,

70–79
shrimp

60–69 Pasta, legumes, salmon, chicken breast

50–59 Ground beef, hot dogs, steak, feta cheese

40–49 Pizza

30–39 Cheddar cheese, bagels, bread

20–29 Pepperoni, cake, biscuits

10–19 Butter, margarine, raisins

Walnuts, dry-roasted peanuts, crackers, cereals, pretzels, peanut

1–9
butter

0 Oils, sugars

Source: National Nutrient Database for Standard Reference, Release 23. US Department of Agriculture, Agricultural Research
Service. [Link] Updated 2010. Accessed September 2017.
There is some debate over the amount of water required to maintain health because there is no consistent scientific evidence
proving that drinking a particular amount of water improves health or reduces the risk of disease. In fact, kidney-stone prevention
seems to be the only premise for water-consumption recommendations. You may be surprised to find out that the commonly held
belief that people need to drink eight 8-ounce glasses of water per day isn’t an official recommendation and isn’t based on any
scientific evidence! The amount of water/fluids a person should consume every day is actually variable and should be based on the
climate a person lives in, as well as their age, physical activity level, and kidney function. No maximum for water intake has been
set.

Thirst Mechanism: Why Do We Drink?

Thirst is an osmoregulatory mechanism to increase water input. The thirst mechanism is activated in response to changes in water
volume in the blood, but is even more sensitive to changes in blood osmolality. Blood osmolality is primarily driven by the
concentration of sodium cations. The urge to drink results from a complex interplay of hormones and neuronal responses that
coordinate to increase water input and contribute toward fluid balance and composition in the body. The “thirst center” is contained
within the hypothalamus, a portion of the brain that lies just above the brainstem. In older people the thirst mechanism is not as
responsive and as we age there is a higher risk for dehydration. Thirst happens in the following sequence of physiological events:
1. Receptor proteins in the kidney, heart, and hypothalamus detect decreased fluid volume or increased sodium concentration in
the blood.
2. Hormonal and neural messages are relayed to the brain’s thirst center in the hypothalamus.
The hypothalamus sends neural signals to higher sensory areas in the cortex of the brain, stimulating the conscious thought to
drink.
3. Fluids are consumed.
4. Receptors in the mouth and stomach detect mechanical movements involved with fluid ingestion.
5. Neural signals are sent to the brain and the thirst mechanism is shut off.

8.4.2 [Link]
The physiological control of thirst is the backup mechanism to increase water input. Fluid intake is controlled primarily by
conscious eating and drinking habits dependent on social and cultural influences. For example, you might have a habit of drinking a
glass of orange juice and eating a bowl of cereal every morning before school or work.

Figure : Regulating Water Intake. Image by Allison Calabrese / CC BY 4.0

Regulation of Daily Water Output

As stated, daily water output averages 2.5 liters. There are two types of outputs. The first type is insensible water loss, meaning we
are unaware of it. The body loses about 400 milliliters of its daily water output through exhalation. Another 500 milliliters is lost
through our skin. The second type of output is sensible water loss, meaning we are aware of it. Urine accounts for about 1,500
milliliters of water output, and feces account for roughly 100 milliliters of water output. Regulating urine output is a primary
function of the kidneys, and involves communication with the brain and endocrine system.

Figure : Regulating Water Output. Image by Allison Calabrese / CC

BY 4.0

The Kidneys Detect Blood Volume

The kidneys are two bean-shaped organs, each about the size of a fist and located on either side of the spine just below the rib cage.
The kidneys filter about 190 liters of blood and produce (on average) 1.5 liters of urine per day. Urine is mostly water, but it also
contains electrolytes and waste products, such as urea. The amount of water filtered from the blood and excreted as urine is
dependent on the amount of water in, and the electrolyte composition in the blood.

8.4.3 [Link]
Kidneys have protein sensors that detect blood volume from the pressure, or stretch, in the blood vessels of the kidneys. When
blood volume is low, kidney cells detect decreased pressure and secrete the enzyme, renin. Renin travels in the blood and cleaves
another protein into the active hormone, angiotensin. Angiotensin targets three different organs (the adrenal glands, the
hypothalamus, and the muscle tissue surrounding the arteries) to rapidly restore blood volume and, consequently, pressure.

The Hypothalamus Detects Blood Osmolality

Sodium and fluid balance are intertwined. Osmoreceptors (specialized protein receptors) in the hypothalamus detect sodium
concentration in the blood. In response to a high sodium level, the hypothalamus activates the thirst mechanism and concurrently
stimulates the release of antidiuretic hormone. Thus, it is not only kidneys that stimulate antidiuretic- hormone release, but also the
hypothalamus. This dual control of antidiuretic hormone release allows for the body to respond to both decreased blood volume
and increased blood osmolality.

The Adrenal Glands Detect Blood Osmolality

Cells in the adrenal glands sense when sodium levels are low and potassium levels are high in the blood. In response to either
stimulus, they release aldosterone. Aldosterone is released in response to angiotensin stimulation and is controlled by blood
electrolyte concentrations. In either case, aldosterone communicates the same message, to increase sodium reabsorption and
consequently water reabsorption. In exchange, for the reabsorption of sodium and water, potassium is excreted.

Resources
1. Institute of Medicine Panel on Dietary Reference Intakes for Electrolytes and Water. (2005). Dietary Reference Intakes for
Water, Potassium, Sodium, Chloride, and Sulfate. The National Academies of Science, Engineering, and Medicine. Washington
D.C. [Link] Accessed September 22, 2017. ↵

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8.4.4 [Link]
8.5: Electrolytes Important for Fluid Balance
Cells are about 75 percent water and blood plasma is about 95 percent water. Why then, does the water not flow from blood plasma
to cells? The force of water also known as hydrostatic pressure maintains the volumes of water between fluid compartments against
the force of all dissolved substances. The concentration is the amount of particles in a set volume of water. (Recall that individual
solutes can differ in concentration between the intracellular and extracellular fluids, but the total concentration of all dissolved
substances is equal.)
The force driving the water movement through the selectively permeable membrane is the higher solute concentration on the one
side. Solutes at different concentrations on either side of a selectively permeable membrane exert a force, called osmotic pressure.
The higher concentration of solutes on one side compared to the other of the U-tube exerts osmotic pressure, pulling the water to a
higher volume on the side of the U-tube containing more dissolved particles. When the osmotic pressure is equal to the pressure of
the water on the selectively permeable membrane, net water movement stops (though it still diffuses back and forth at an equal
rate).
One equation exemplifying equal concentrations but different volumes is the following
5 grams of glucose in 1 liter = 10 grams of glucose in 2 liters (5g/L = 5g/L)
The differences in concentrations of particular substances provide concentration gradients that cells can use to perform work. A
concentration gradient is a form of potential energy, like water above a dam. When water falls through a dam the potential energy is
changed to moving energy (kinetic), that in turn is captured by turbines. Similarly, when an electrolyte at higher concentration in
the extracellular fluid is transported into a cell, the potential energy is harnessed and used to perform work.
Cells are constantly transporting nutrients in and wastes out. How is the concentration of solutes maintained if they are in a state of
flux? This is where electrolytes come into play. The cell (or more specifically the numerous sodium-potassium pumps in its
membrane) continuously pumps sodium ions out to establish a chemical gradient. The transport protein, called the glucose
symporter, uses the sodium gradient to power glucose movement into the cell. Sodium and glucose both move into the cell. Water
passively follows the sodium. To restore balance, the sodium-potassium pump transfers sodium back to the extracellular fluid and
water follows. Every cycle of the sodium-potassium pump involves the movement of three sodium ions out of a cell, in exchange
for two potassium ions into a cell. To maintain charge neutrality on the outside of cells every sodium cation is followed by a
chloride anion. Every cycle of the pump costs one molecule of ATP (adenosine triphosphate). The constant work of the sodium-
potassium pump maintains the solute equilibrium and consequently, water distribution between intracellular and extracellular
fluids.
The unequal movement of the positively charged sodium and potassium ions makes intracellular fluid more negatively charged
than the extracellular fluid. This charge gradient is another source of energy that a cell uses to perform work. You will soon learn
that this charge gradient and the sodium-potassium pump are also essential for nerve conduction and muscle contraction. The many
functions of the sodium-potassium pump in the body account for approximately a quarter of total resting energy expenditure.

8.5.1 [Link]
 Figure : The Sodium-Potassium Pump. The
sodium-potassium pump is the primary mechanism for cells to maintain water balance between themselves and their surrounding
environment.

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8.5.2 [Link]
8.6: Sodium
Sodium is vital not only for maintaining fluid balance but also for many other essential functions. In contrast to many minerals,
sodium absorption in the small intestine is extremely efficient and in a healthy individual all excess sodium is excreted by the
kidneys. In fact, very little sodium is required in the diet (about 200 milligrams) because the kidneys actively reabsorb sodium.
Kidney reabsorption of sodium is hormonally controlled, allowing for a relatively constant sodium concentration in the blood.

Other Functions of Sodium in the Body

The second notable function of sodium is in nerve impulse transmission. Nerve impulse transmission results from the transport of
sodium cations into a nerve cell, which creates a charge difference (or voltage) between the nerve cell and its extracellular
environment. Similar to how a current moves along a wire, a sodium current moves along a nerve cell. Stimulating a muscle
contraction also involves the movement of sodium ions as well as other ion movements.
Sodium is essential for nutrient absorption in the small intestine and also for nutrient reabsorption in the kidney. Amino acids,
glucose and water must make their way from the small intestine to the blood. To do so, they pass through intestinal cells on their
way to the blood. The transport of nutrients through intestinal cells is facilitated by the sodium-potassium pump, which by moving
sodium out of the cell, creates a higher sodium concentration outside of the cell (requiring ATP).

Sodium Imbalances
Sweating is a homeostatic mechanism for maintaining body temperature, which influences fluid and electrolyte balance. Sweat is
mostly water but also contains some electrolytes, mostly sodium and chloride. Under normal environmental conditions (i.e., not
hot, humid days) water and sodium loss through sweat is negligible, but is highly variable among individuals. It is estimated that
sixty minutes of high-intensity physical activity, like playing a game of tennis, can produce approximately one liter of sweat;
however the amount of sweat produced is highly dependent on environmental conditions. A liter of sweat typically contains
between 1 and 2 grams of sodium and therefore exercising for multiple hours can result in a high amount of sodium loss in some
people. Additionally, hard labor can produce substantial sodium loss through sweat. In either case, the lost sodium is easily
replaced in the next snack or meal.
In athletes hyponatremia, or a low blood-sodium level, is not so much the result of excessive sodium loss in sweat, but rather
drinking too much water. The excess water dilutes the sodium concentration in blood. Illnesses causing vomiting, sweating, and
diarrhea may also cause hyponatremia. The symptoms of hyponatremia, also called water intoxication (since it is often the root
cause) include nausea, muscle cramps, confusion, dizziness, and in severe cases, coma and death. The physiological events that
occur in water intoxication are the following:
1. Excessive sodium loss and/or water intake.
2. Sodium levels fall in blood and in the fluid between cells.
3. Water moves to where solutes are more concentrated (i.e. into cells).
4. Cells swell.
5. Symptoms, including nausea, muscle cramps, confusion, dizziness, and in severe cases, coma and death result.
Hyponatremia in endurance athletes (such as marathon runners) can be avoided by drinking the correct amount of water, which is
about 1 cup every twenty minutes during the event. Sports drinks are better at restoring fluid and blood-glucose levels than
replacing electrolytes. During an endurance event you would be better off drinking water and eating an energy bar that contains
sugars, proteins, and electrolytes. The American College of Sports Medicine suggests if you are exercising for longer than one hour
you eat one high carbohydrate (25–40 grams) per hour of exercise along with ample water.[1]
Watch out for the fat content, as sometimes energy bars contain a hefty dose. If you’re not exercising over an hour at high intensity,
you can skip the sports drinks, but not the water. For those who do not exercise or do so at low to moderate intensity, sports drinks
are another source of extra calories, sugar, and salt.

Needs and Dietary Sources of Sodium

The IOM has set an AI level for sodium for healthy adults between the ages of nineteen and fifty at 1,500 milligrams (Table 3.2).
Table salt is approximately 40 percent sodium and 60 percent chloride. As a reference point, only ⅔ teaspoon of salt is needed in

8.6.1 [Link]
the diet to meet the AI for sodium. The AI takes into account the amount of sodium lost in sweat during recommended physical
activity levels and additionally provides for the sufficient intake of other nutrients, such as chloride. The Tolerable Upper Intake
Level (UL) for sodium is 2,300 milligrams per day for adults. (Just over 1 teaspoon of salt contains the 2,300 milligrams of sodium
recommended). The UL is considered appropriate for healthy individuals but not those with hypertension (high blood pressure).
The IOM estimates that greater than 95 percent of men and 75 percent of women in America consume salt in excess of the UL.
Many scientific studies demonstrate that reducing salt intake prevents hypertension, is helpful in reducing blood pressure after
hypertension is diagnosed, and reduces the risk for cardiovascular disease. The IOM recommends that people over fifty, African
Americans, diabetics, and those with chronic kidney disease should consume no more than 1,500 milligrams of sodium per day.
The American Heart Association (AHA) states that all Americans, not just those listed, should consume less than 1,500 milligrams
of sodium per day to prevent cardiovascular disease. The AHA recommends this because millions of people have risk factors for
hypertension and there is scientific evidence supporting that lower-sodium diets are preventive against hypertension.
Table : Dietary Reference Intakes for Sodium

Age Group Adequate Intake(mg/day) Tolerable Upper Intake Level (mg/day)

Infants (0–6 months) 120 ND

Infants (6–12 months) 370 ND

Children (1–3 years) 1,000 1,500

Children (4–8 years) 1,200 1,900

Children (9–13 years) 1,500 2,200

Adolescents (14–18 years) 1,500 2,300

Adults (19–50 years) 1,500 2,300

Adults (50–70 years) 1,300 2,300

Adults (> 70 years) 1,200 2,300

ND = not determined

Source: Dietary Reference Intakes: Water, Potassium, Sodium, Chloride, and Sulfate. Institute of Medicine.
[Link]/Reports/2004/[Link]. Updated February
11, 2004. Accessed September 22, 2017.

Food Sources for Sodium

Most sodium in the typical American diet comes from processed and prepared foods. Manufacturers add salt to foods to improve
texture and flavor, and also as a preservative. The amount of salt in similar food products varies widely. Some foods, such as meat,
poultry, and dairy foods, contain naturally-occurring sodium. For example, one cup of low-fat milk contains 107 milligrams of
sodium. Naturally-occurring sodium accounts for less than 12 percent of dietary intake in a typical diet. For the sodium contents of
various foods see Table 3.3.

8.6.2 [Link]
 Figure : Dietary Sources of Sodium. “Food Eat Salt” by Clker-Free-Vector-
Images / Pixabay License
Table : Sodium Contents of Selected Foods

8.6.3 [Link]
Food Group Serving Size Sodium (mg)

Breads, all types 1 oz. 95–210

Rice Chex cereal 1 ¼ c. 292

Raisin Bran cereal 1 c. 362

Frozen pizza, plain, cheese 4 oz. 450–1200

Frozen vegetables, all types ½ c. 2–160

Salad dressing, regular fat, all types 2 Tbsp. 110–505

Salsa 2 Tbsp. 150–240

Soup (tomato), reconstituted 8 oz. 700–1260

Potato chips 1 oz. (28.4 g) 120–180

Tortilla chips 1 oz. (28.4 g) 105–160

Pork 3 oz. 59

Chicken (½ breast) 69

Chicken fast food dinner 2243

Chicken noodle soup 1 c. 1107

Dill pickle 1 928

Soy sauce 1 Tbsp. 1029

Canned corn 1 c. 384

Baked beans, canned 1 c. 856

Hot dog 1 639

Burger, fast-food 1 990

Steak 3 oz. 55

Canned tuna 3 oz. 384

Fresh tuna 3 oz. 50

Dry-roasted peanuts 1 c. 986

American cheese 1 oz. 406

Tap water 8 oz. 12

8.6.4 [Link]
Sodium on the Nutrition Facts Panel

Figure : Nutrition Label. Sodium levels in milligrams is a required listing on a

Nutrition Facts label.
The Nutrition Facts panel displays the amount of sodium (in milligrams) per serving of the food in question (Figure ). Food
additives are often high in sodium, for example, monosodium glutamate (MSG) contains 12 percent sodium. Additionally, baking
soda, baking powder, disodium phosphate, sodium alginate, and sodium nitrate or nitrite contain a significant proportion of sodium
as well. When you see a food’s Nutrition Facts label, you can check the ingredients list to identify the source of the added sodium.
Various claims about the sodium content in foods must be in accordance with Food and Drug Administration (FDA) regulations
(Table ).
Table : Food Packaging Claims Regarding Sodium

Claim Meaning

“Light in Sodium” or “Low in Sodium” Sodium is reduced by at least 50 percent

“No Salt Added” or “Unsalted” No salt added during preparation and processing*

“Lightly Salted” 50 percent less sodium than that added to similar food

“Sodium Free” or “Salt Free” Contains less than 5 mg sodium per serving

“Very Low Salt” Contains less than 35 mg sodium per serving

“Low Salt” Contains less than 140 mg sodium per serving

*Must also declare on package “This is not a sodium-free food” if

food is not sodium-free

Source: Food Labeling Guide. US Food and Drug Administration.

[Link]/Food/GuidanceComplianceRegulatoryInformation/GuidanceDocuments/FoodLabelingNutrition/FoodLabelingGuide/
[Link]. Updated October 2009. Accessed October 2, 2011.

8.6.5 [Link]
Tools for Change
To decrease your sodium intake, become a salt-savvy shopper by reading the labels and ingredients lists of processed foods and
choosing those lower in salt. Even better, stay away from processed foods and control the seasoning of your foods. Eating a diet
with less salty foods diminishes salt cravings so you may need to try a lower sodium diet for a week or two before you will be
satisfied with the less salty food.

Salt Substitutes
For those with hypertension or those looking for a way to decrease salt use, using a salt substitute for food preparation is one
option. However, many salt substitutes still contain sodium, just in lesser amounts than table salt. Also, remember that most salt in
the diet is not from table-salt use, but from processed foods. Salt substitutes often replace the sodium with potassium. People with
kidney disorders often have problems getting rid of excess potassium in the diet and are advised to avoid salt substitutes containing
potassium. People with liver disorders should also avoid salt substitutes containing potassium because their treatment is often
accompanied by potassium dysregulation. Table displays the sodium and potassium amounts in some salt substitutes.
Table : Salt Substitutes
Product Serving Size Sodium (mg) Potassium (mg)

Salt 1 tsp. 2,300 0

Mrs. Dash 1 tsp. 0 40

Spike (Salt-Free) 1 tsp. 0 96

Veg-It 1 tsp. <65 <65

Accent Low-Sodium Seasoning 1 tsp. 600 0

Salt Sense 1 tsp. 1,560 0

Pleasoning Mini-Mini Salt 1 tsp. 440 0

Morton Lite Salt 1 tsp. 1,100 1,500

Estee Salt-It 1 tsp. 0 3,520

Morton Nature’s Seasons 1 tsp. 1,300 2,800

Morton Salt Substitute 1 tsp. 0 2,730

No Salt 1 tsp. 5 2,500

Nu-Salt 1 tsp. 0 529

Source: Health Facts for You: Guidelines for a Low Sodium Diet. University of Wisconsin Hospitals and Clinics Authority.
[Link]/health-topic...nts/[Link]. Updated March 2011. Accessed September 22, 2017.

Alternative Seasonings
Table salt may seem an essential ingredient of good food, but there are others that provide alternative taste and zest to your foods.
See Table for an AHA list of alternative food seasonings.
Table Salt Alternatives

8.6.6 [Link]
 Seasoning Foods

Lean ground meats, stews, tomatoes, peaches, applesauce,

Allspice
cranberry sauce, gravies, lean meat

Almond extract Puddings, fruits

Lean meats, stews, soups, salads, breads, cabbage, asparagus,

Caraway seeds
noodles

Chives Salads, sauces, soups, lean-meat dishes, vegetables

Cider vinegar Salads, vegetables, sauces

Cinnamon Fruits, breads, pie crusts

Lean meats (especially lamb), veal, chicken, fish, tomatoes,

Curry powder
tomato soup, mayonnaise,
fish sauces, soups, tomatoes, cabbages, carrots, cauliflower, green
Dill
beans, cucumbers, potatoes, salads, macaroni, lamb

Garlic (not garlic salt) Lean meats, fish, soups, salads, vegetables, tomatoes, potatoes

Ginger Chicken, fruits

Lemon juice Lean meats, fish, poultry, salads, vegetables

Hot breads, apples, fruit salads, carrots, cauliflower, squash,

Mace
potatoes, veal, lamb

lean ground meats, lean meats, chicken, fish, salads, asparagus,

Mustard (dry)
broccoli, Brussels sprouts, cabbage, mayonnaise, sauces
Fruits, pie crust, lemonade, potatoes, chicken, fish, lean meatloaf,
Nutmeg
toast, veal, pudding

Onion powder Lean meats, stews, vegetables, salads, soups

Paprika Lean meats, fish, soups, salads, sauces, vegetables

Parsley Lean meats, fish, soups, salads, sauces, vegetables

Peppermint extract Puddings, fruits

Pimiento Salads, vegetables, casserole dishes

Chicken, veal, lean meatloaf, lean beef, lean pork, sauces,

Rosemary
stuffings, potatoes, peas, lima beans
Lean meats, stews, biscuits, tomatoes, green beans, fish, lima
Sage
beans, onions, lean pork
Salads, lean pork, lean ground meats, soups, green beans, squash,
Savory
tomatoes, lima beans, peas

Lean meats (especially veal and lean pork), sauces, soups, onions,
Thyme
peas, tomatoes, salads

Turmeric Lean meats, fish, sauces, rice

Source: Shaking the Salt Habit. American Heart Association.

[Link]
Habit_UCM_303241_Article.jsp. Updated June 6, 2012. Accessed September 22, 2017.

8.6.7 [Link]
Resources
1. Convertino VA, et al. (1996). American College of Sports Medicine Position Stand. Exercise and Fluid Replacement. Medicine
and Science in Sports and Exercise, 28(1) i–vii. [Link] Accessed September 22, 2017.
↵

This page titled 8.6: Sodium is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper, Marie
Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.
3.6: Sodium by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original source:
[Link]

8.6.8 [Link]
8.7: Chloride
Chloride is the primary anion in extracellular fluid. In addition to passively following sodium, chloride has its own protein channels
that reside in cell membranes. These protein channels are especially abundant in the gastrointestinal tract, pancreas, and lungs.

Chloride’s Role in Fluid Balance

Chloride aids in fluid balance mainly because it follows sodium in order to maintain charge neutrality. Chloride channels also play
a role in regulating fluid secretion, such as pancreatic juice into the small intestine and the flow of water into mucus. Fluid
secretion and mucus are important for many of life’s processes. Their importance is exemplified in the signs and symptoms of the
genetic disease, cystic fibrosis.

Cystic Fibrosis
Cystic fibrosis (CF) is one of the most prevalent inherited diseases in people of European descent. It is caused by a mutation in a
protein that transports chloride ions out of the cell. CF’s signs and symptoms include salty skin, poor digestion and absorption
(leading to poor growth), sticky mucus accumulation in the lungs (causing increased susceptibility to respiratory infections), liver
damage, and infertility.

Other Functions of Chloride

Chloride has several other functions in the body, most importantly in acid-base balance. Blood pH is maintained in a narrow range
and the number of positively charged substances is equal to the number of negatively charged substances. Proteins, such as
albumin, as well as bicarbonate ions and chloride ions, are negatively charged and aid in maintaining blood pH. Hydrochloric acid
(a gastric acid composed of chlorine and hydrogen) aids in digestion and also prevents the growth of unwanted microbes in the
stomach. Immune-system cells require chloride, and red blood cells use chloride anions to remove carbon dioxide from the body.

Chloride Imbalances
Low dietary intake of chloride and more often diarrhea can cause low blood levels of chloride. Symptoms typically are similar to
those of hyponatremia and include weakness, nausea, and headache. Excess chloride in the blood is rare with no characteristic signs
or symptoms.

Needs and Dietary Sources of Chloride

Most chloride in the diet comes from salt. (Salt is 60 percent chloride.) A teaspoon of salt equals 5,600 milligrams, with each
teaspoon of salt containing 3,400 milligrams of chloride and 2,200 milligrams of sodium. The chloride AI for adults, set by the
IOM, is 2,300 milligrams. Therefore just ⅔ teaspoon of table salt per day is sufficient for chloride as well as sodium. The AIs for
other age groups are listed in Table .
Table : Adequate Intakes for Chloride

8.7.1 [Link]
 Age Group mg/day

Infants (0–6 months) 180

Infants (6–12 months) 570

Children (1–3 years) 1,500

Children (4–8 years) 1,900

Children (9–13 years) 2,300

Adolescents (14–18 years) 2,300

Adults (19–50 years) 2,300

Adults (51–70 years) 2,000

Adults (> 70 years) 1,800

Source: Dietary Reference Intakes: Water, Potassium, Sodium, Chloride, and Sulfate. Institute of Medicine.
[Link]/Reports/2004/[Link]. Updated February
11, 2004. Accessed September 22, 2017.

Other Dietary Sources of Chloride

Chloride has dietary sources other than table salt, namely as another form of salt—potassium chloride. Dietary sources of chloride
are: all foods containing sodium chloride, as well as tomatoes, lettuce, olives, celery, rye, whole-grain foods, and seafood. Although
many salt substitutes are sodium-free, they may still contain chloride.

Bioavailability
Bioavailability refers to the amount of a particular nutrient in foods that is actually absorbed in the intestine and not eliminated in
the urine or feces. Simply put, the bioavailability of chloride is the amount that is on hand to perform its biological functions. In the
small intestine, the elements of sodium chloride split into sodium cations and chloride anions. Chloride follows the sodium ion into
intestinal cells passively, making chloride absorption quite efficient. When chloride exists as a potassium salt, it is also well
absorbed. Other mineral salts, such as magnesium chloride, are not absorbed as well, but bioavailability still remains high.

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Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.
3.7: Chloride by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original source:
[Link]

8.7.2 [Link]
8.8: Potassium
Potassium is the most abundant positively charged ion inside of cells. Ninety percent of potassium exists in intracellular fluid, with
about 10 percent in extracellular fluid, and only 1 percent in blood plasma. As with sodium, potassium levels in the blood are
strictly regulated. The hormone aldosterone is what primarily controls potassium levels, but other hormones (such as insulin) also
play a role. When potassium levels in the blood increase, the adrenal glands release aldosterone. The aldosterone acts on the
collecting ducts of kidneys, where it stimulates an increase in the number of sodium-potassium pumps. Sodium is then reabsorbed
and more potassium is excreted. Because potassium is required for maintaining sodium levels, and hence fluid balance, about 200
milligrams of potassium are lost from the body every day.

Other Functions of Potassium in the Body

Nerve impulse involves not only sodium, but also potassium. A nerve impulse moves along a nerve via the movement of sodium
ions into the cell. To end the impulse, potassium ions rush out of the nerve cell, thereby decreasing the positive charge inside the
nerve cell. This diminishes the stimulus. To restore the original concentrations of ions between the intracellular and extracellular
fluid, the sodium-potassium pump transfers sodium ions out in exchange for potassium ions in. On completion of the restored ion
concentrations, a nerve cell is now ready to receive the next impulse. Similarly, in muscle cells potassium is involved in restoring
the normal membrane potential and ending the muscle contraction. Potassium also is involved in protein synthesis, energy
metabolism, and platelet function, and acts as a buffer in blood, playing a role in acid-base balance.

Imbalances of Potassium
Insufficient potassium levels in the body (hypokalemia) can be caused by a low dietary intake of potassium or by high sodium
intakes, but more commonly it results from medications that increase water excretion, mainly diuretics. The signs and symptoms of
hypokalemia are related to the functions of potassium in nerve cells and consequently skeletal and smooth-muscle contraction. The
signs and symptoms include muscle weakness and cramps, respiratory distress, and constipation. Severe potassium depletion can
cause the heart to have abnormal contractions and can even be fatal. High levels of potassium in the blood, or hyperkalemia, also
affects the heart. It is a silent condition as it often displays no signs or symptoms. Extremely high levels of potassium in the blood
disrupt the electrical impulses that stimulate the heart and can cause the heart to stop. Hyperkalemia is usually the result of kidney
dysfunction.

Needs and Dietary Sources of Potassium

The IOM based their AIs for potassium on the levels associated with a decrease in blood pressure, a reduction in salt sensitivity,
and a minimal risk of kidney stones. For adult male and females above the age of nineteen, the adequate intake for potassium is
4,700 grams per day. The AIs for other age groups are listed in Table .
Table : Adequate Intakes for Potassium

Age Group mg/day

Infants (0–6 months) 400

Infants (6–12 months) 700

Children (1–3 years) 3,000

Children (4–8 years) 3,800

Children (9–13 years) 4,500

Adolescents (14–18 years) 4,700

Adults (> 19 years) 4,700

Dietary Reference Intakes: Water, Potassium, Sodium, Chloride, and Sulfate. Institute of Medicine.
[Link]/Reports/2004/[Link]. Updated February

8.8.1 [Link]
11, 2004. Accessed September 22, 2017.

Food Sources for Potassium

Fruits and vegetables that contain high amounts of potassium are spinach, lettuce, broccoli, peas, tomatoes, potatoes, bananas,
apples and apricots. Whole grains and seeds, certain fish (such as salmon, cod, and flounder), and meats are also high in potassium.
The Dietary Approaches to Stop Hypertension (DASH diet) emphasizes potassium-rich foods and will be discussed in greater detail
in the next section.

Bioavailability
Greater than 90 percent of dietary potassium is absorbed in the small intestine. Although highly bioavailable, potassium is a very
soluble mineral and easily lost during cooking and processing of foods. Fresh and frozen foods are better sources of potassium than
canned.

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3.8: Potassium by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original source:
[Link]

8.8.2 [Link]
8.9: Consequences of Deficiency or Excess
As with all nutrients, having too much or too little water has health consequences. Excessive water intake can dilute the levels of
critical electrolytes in the blood. Water intoxication is rare, however when it does happen, it can be deadly. On the other hand,
having too little water in the body is common. In fact, diarrhea-induced dehydration is the number-one cause of early-childhood
death worldwide. In this section we will discuss subtle changes in electrolytes that compromise health on a chronic basis.

High-Hydration Status: Water Intoxication/Hyponatremia

Water intoxication mainly affects athletes who overhydrate. Water intoxication is extremely rare, primarily because healthy kidneys
are capable of excreting up to one liter of excess water per hour. Overhydration was unfortunately demonstrated in 2007 by
Jennifer Strange, who drank six liters of water in three hours while competing in a “Hold Your Wee for a Wii” radio contest.
Afterward she complained of a headache, vomited, and died.

Low-Hydration Status: Dehydration

Dehydration refers to water loss from the body without adequate replacement. It can result from either water loss or electrolyte
imbalance, or, most commonly, both. Dehydration can be caused by prolonged physical activity without adequate water intake, heat
exposure, excessive weight loss, vomiting, diarrhea, blood loss, infectious diseases, malnutrition, electrolyte imbalances, and very
high glucose levels. Physiologically, dehydration decreases blood volume. The water in cells moves into the blood to compensate
for the low blood-volume, and cells shrink. Signs and symptoms of dehydration include thirst, dizziness, fainting, headaches, low
blood-pressure, fatigue, low to no urine output, and, in extreme cases, loss of consciousness and death. Signs and symptoms are
usually noticeable after about 2 percent of total body water is lost.
Chronic dehydration is linked to higher incidences of some diseases. There is strong evidence that low-hydration status increases
the risk for kidney stones and exercise-induced asthma. There is also some scientific evidence that chronic dehydration increases
the risk for kidney disease, heart disease, and the development of hyperglycemia in people with diabetes. Older people often suffer
from chronic dehydration as their thirst mechanism is no longer as sensitive as it used to be.

Heat Stroke
Heat stroke is a life-threatening condition that occurs when the body temperature is greater than 104°F (40°C). It is the result of the
body being unable to sufficiently cool itself by thermoregulatory mechanisms. Dehydration is a primary cause of heat stroke as
there are not enough fluids in the body to maintain adequate sweat production, and cooling of the body is impaired. Signs and
symptoms are dry skin (absence of sweating), dizziness, trouble breathing, rapid pulse, confusion, agitation, seizures, coma, and
possibly death. Dehydration may be preceded by heat exhaustion, which is characterized by heavy sweating, rapid breathing, and
fast pulse. The elderly, infants, and athletes are the most at risk for heat stroke.

Hypertension
Blood pressure is the force of moving blood against arterial walls. It is reported as the systolic pressure over the diastolic pressure,
which is the greatest and least pressure on an artery that occurs with each heartbeat. The force of blood against an artery is
measured with a device called a sphygmomanometer. The results are recorded in millimeters of mercury, or mmHg. A desirable
blood pressure is less than 120/80 mm Hg. Hypertension is the scientific term for high blood pressure and defined as a sustained
blood pressure of 130/80 mm Hg or greater.[1] Hypertension is a risk factor for cardiovascular disease, and reducing blood pressure
has been found to decrease the risk of dying from a heart attack or stroke. The Centers for Disease Control and Prevention (CDC)
reported that in 2007–2008 approximately 33 percent of Americans were hypertensive.[2]The percentage of people with
hypertension increases to over 60 percent in people over the age of sixty.

8.9.1 [Link]
 Figure : Measuring Blood Pressure. Testing a GIs blood pressure at
Guantanamo by Charlie Helmholt / Public Domain
There has been much debate about the role sodium plays in hypertension. In the latter 1980s and early 1990s the largest
epidemiological study evaluating the relationship of dietary sodium intake with blood pressure, called INTERSALT, was completed
and then went through further analyses.[3][4]
More than ten thousand men and women from thirty-two countries participated in the study. The study concluded that a higher
sodium intake is linked to an increase in blood pressure. A more recent study, involving over twelve thousand US citizens,
concluded that a higher sodium-to-potassium intake is linked to higher cardiovascular mortality and all-causes mortality.[5]
The DASH-Sodium trial was a clinical trial which evaluated the effects of a specified eating plan with or without reduced sodium
intake. The DASH diet is an eating plan that is low in saturated fat, cholesterol, and total fat. Fruits, vegetables, low-fat dairy foods,
whole-grain foods, fish, poultry, and nuts are emphasized while red meats, sweets, and sugar-containing beverages are mostly
avoided. In this study, people on the low-sodium (1500 milligrams per day) DASH diet had mean systolic blood pressures that were
7.1 mmHg lower than people without hypertension not on the DASH diet. The effect on blood pressure was greatest in participants
with hypertension at the beginning of the study who followed the DASH diet. Their systolic blood pressures were, on average, 11.5
mmHg lower than participants with hypertension on the control diet.[6]
Following the DASH diet not only reduces sodium intake, but also increases potassium, calcium, and magnesium intake. All of
these electrolytes have a positive effect on blood pressure, although the mechanisms by which they reduce blood pressure are
largely unknown.
While some other large studies have demonstrated little or no significant relationship between sodium intake and blood pressure,
the weight of scientific evidence demonstrating low-sodium diets as effective preventative and treatment measures against
hypertension led the US government to pass a focus on salt within the Consolidated Appropriations Act of 2008. A part of this act
tasked the CDC, under guidance from the IOM, to make recommendations for Americans to reduce dietary sodium intake. This
task is ongoing and involves “studying government approaches (regulatory and legislative actions), food supply approaches (new
product development, food reformulation), and information/education strategies for the public and professionals.”[7]

Try for Yourself

The National Heart, Lung, and Blood Institute has prepared an informative fact sheet on the DASH diet:
[Link]
Use the food-group charts to help design a daily menu that follows the DASH eating plan.

8.9.2 [Link]
Figure : “Your Guide to Lowering Blood Pressure”. US Department of Health Services

Salt Sensitivity
High dietary intake of sodium is one risk factor for hypertension and contributes to high blood pressure in many people. However,
studies have shown that not everyone’s blood pressure is affected by lowering sodium intake. About 10 to 20 percent of the
population is considered to be salt-sensitive, meaning their blood pressure is affected by salt intake. Genetics, race, gender, weight,
and physical activity level are determinants of salt sensitivity. African Americans, women, and overweight individuals are more
salt-sensitive than others. Also, if hypertension runs in a person’s family, that person is more likely to be salt-sensitive. Because
reducing dietary salt intake will not work for everyone with hypertension or a risk for developing the condition, there are many
opponents of reducing dietary salt intake at the national level. Among such opponents is the Salt Institute, a nonprofit trade
organization that states, “No evidence demonstrates that current salt intake levels lead to worse health outcomes such as more heart
attacks or higher cardiovascular mortality.”[8]

Resources
1. New ACC/AHA High Blood Pressure Guidelines Lower Definition of Hypertension. (n.d.). American College of Cardiology.
Retrieved July 2, 2020, from http%3a%2f%[Link]%2flatest-in-
cardiology%2farticles%2f2017%2f11%2f08%2f11%2f47%2fmon-5pm-bp-guideline-aha-2017
↵
2. Centers for Disease Control and Prevention. “FastStats—Hypertension.” Accessed October 2, 2011.
[Link] ↵
3. Intersalt Cooperative Research Group. (1988). Intersalt: An International Study of Electrolyte Excretion and Blood Pressure.
Results for 24 Hour Urinary Sodium and Potassium Excretion. British Medical Journal, 297(6644), 319–28.
[Link] Accessed September 20, 2017. ↵
4. Elliott P, Stamler J, et al. (1996). Intersalt Revisited: Further Analyses of 24 Hour Sodium Excretion and Blood Pressure within
and across Populations. British Medical Journal, 312(7041), 1249–53. [Link]

8.9.3 [Link]
 Accessed September 22, 2017. ↵
5. Yang Q, Liu T, et al. (2011). Sodium and Potassium Intake and Mortality among US Adults: Prospective Data from the Third
National Health and Nutrition Examination Survey. Archives of Internal Medicine, 171(13), 1183–91.
[Link] Accessed September 22, 2017. ↵
6. Sacks, FM, Svetkey LP, et al. (2001). Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to
Stop Hypertension (DASH) Diet. New England Journal of Medicine, 344(1), 3–10.
[Link] Accessed September 22, 2017. ↵
7. Henney JE, Taylor CL, Boon CS. (2010). Strategies to Reduce Sodium Intake in the United States, by Committee on Strategies
to Reduce Sodium Intake, Institute of Medicine. Washington, D.C.: National Academies Press.
[Link] 19#p2001bcf59960019001. Accessed September 22, 2017. ↵
8. Salt and Health. The Salt Institute. [Link]/Issues-in-focus/Food-salt-health. Updated 2011. Accessed October 2,
2011. ↵

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curated by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
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8.9.4 [Link]
8.10: Water Concerns
At this point you have learned how critical water is to support human life, how it is distributed and moved in the body, how fluid
balance and composition is maintained, and the recommended amount of fluids a person should consume daily. In America you
have a choice of thousands of different beverages. Which should you choose to receive the most health benefit and achieve your
recommended fluid intake?

Reading the Label

Most beverages marketed in the United States have a Nutrition Facts panel and ingredients list, but some, such as coffee (for home
consumption), beer, and wine, do not. As with foods, beverages that are nutrient-dense are the better choices, with the exception of
plain water, which contains few to no other nutrients. Beverages do not make you full; they satiate your thirst. Therefore, the fewer
calories in a beverage the better it is for avoiding weight gain. For an estimate of kilocalories in various beverages see Table .
Table : Calories in Various Beverages

Beverage Serving Size (oz) Kilocalories

Soda 12.0 124–189

Bottled sweet tea 12.0 129–143

Orange juice 12.0 157–168

Tomato/vegetable juice 12.0 80

Whole milk 12.0 220

Nonfat milk 12.0 125

Soy milk 12.0 147–191

Coffee, black 12.0 0–4

Coffee, with cream 12.0 39–43

Caffe latte, whole milk 12.0 200

Sports drink 12.0 94

Beer 12.0 153

White wine 5.0 122

Beverage Consumption in the United States

According to the Beverage Marketing Corporation, in the United States in 2010 Americans consumed 29,325 millions of gallons of
refreshment beverages including soft drinks, coffee, tea, sports drinks, energy drinks, fruit drinks, and bottled water.[1]
As in the past, carbonated soft drinks remained the largest category of consumed beverages. In recent decades total caloric
consumption has increased in the United States and is largely attributed to increased consumption of snacks and caloric beverages.
People between the ages of nineteen and thirty-nine obtain 10 percent of their total energy intake from soft drinks.[2]
In all age groups the consumption of total beverages provides, on average, 21 percent of daily caloric intake. This is 7 percent
higher than the IOM acceptable caloric intake from beverages. Moreover, the high intakes of soft drinks and sugary beverages
displace the intake of more nutrient-dense beverages, such as low-fat milk.
Scientific studies have demonstrated that while all beverages are capable of satisfying thirst they do not make you feel full, or
satiated. This means that drinking a calorie-containing beverage with a meal only provides more calories, as it won’t be offset by
eating less food. The Beverage Panel of the University of North Carolina, Chapel Hill has taken on the challenge of scientifically
evaluating the health benefits and risks of beverage groups and providing recommendations for beverage groups (Table ). In

8.10.1 [Link]
regards to soft drinks and fruit drinks, The Beverage Panel states that they increase energy intake, are not satiating, and that there is
little if any reduction in other foods to compensate for the excess calories. All of these factors contribute to increased energy intake
and obesity.[3]
The Beverage Panel recommends an even lower intake of calories from beverages than IOM—10 percent or less of total caloric
intake.
Table : Recommendations of the Beverage Panel

Beverage Servings per day*

Water ≥ 4 (women), ≥ 6 (men)

Unsweetened coffee and tea ≤ 8 for tea, ≤ 4 for coffee

Nonfat and low-fat milk; fortified soy drinks ≤2

Diet beverages with sugar substitutes ≤4

100 percent fruit juices, whole milk, sports drinks ≤1

Calorie-rich beverages without nutrients ≤ 1, less if trying to lose weight

*One serving is eight ounces.

Source: Beverage Panel Recommendations and Analysis. University of North Carolina, Chapel Hill. US Beverage Guidance
Council. [Link] Accessed November 6, 2012.

Sources of Drinking Water

The Beverage Panel recommends that women drink at least 32 ounces and men drink at least 48 ounces of water daily. In 1974, the
US federal government enacted The Safe Drinking Water Act with the intention of providing the American public with safe
drinking water. This act requires the Environmental Protection Agency (EPA) to set water-quality standards and assure that the
150,000-plus public water systems in the country adhere to the standards. About 15 percent of Americans obtain drinking water
from private wells, which are not subject to EPA standards. Producing water safe for drinking involves some or all of the following
processes: screening out large objects, removing excess calcium carbonate from hard water sources, flocculation, which adds a
precipitating agent to remove solid particles, clarification, sedimentation, filtration, and disinfection. These processes aim to
remove unhealthy substances and produce high-quality, colorless, odorless, good-tasting water. Most drinking water is disinfected
by the process of chlorination, which involves adding chlorine compounds to the water. Chlorination is cheap and effective at
killing bacteria. However, it is less effective at removing protozoa, such as Giardia lamblia. Chlorine-resistant protozoa and viruses
are instead removed by extensive filtration methods. In the decades immediately following the implementation of water
chlorination and disinfection methods in this country, waterborne illnesses, such as cholera and typhoid fever, essentially
disappeared in the United States (Figure ). In fact, the treatment of drinking water is touted as one of the top public-health
achievements of the last century.

8.10.2 [Link]
 Figure : Deadly Water-borne Illnesses In
United States. Deadly water-borne illnesses decreased to almost nonexistent levels in the United States after the implementation of
water disinfection methods. Source: Image credit Robert Tauxe. Drinking Water Week. Centers for Disease Control and Prevention.
[Link] Updated May 17, 2012. Aceessed September 22, 2017.
Chlorine reaction with inadequately filtered water can result in the formation of potentially harmful substances. Some of these
chlorinated compounds, when present at extremely high levels, have been shown to cause cancer in studies conducted in rodents. In
addition to many other contaminants, the EPA has set maximum contaminant levels (legal threshold limits) for these chlorinated
compounds in water, in order to guard against disease risk. The oversight of public water systems in this country is not perfect and
water-borne illnesses are significantly underreported; however, there are far fewer cases of water-borne illnesses than those
attributed to food-borne illnesses that have occurred in the recent past.

Resources
1. US Liquid Refreshment Beverage Market Increased by 1.2% in 2010, Beverage Marketing Corporation Reports. Beverage
Marketing Corporation. [Link] Published 2010. Accessed March 17, 2011.
↵
2. Beverage Intake in the United States. The Beverage Panel, University of North Carolina, Chapel Hill.
[Link] Accessed October 2, 2011. (See Figure 6.8.) ↵
3. US Liquid Refreshment Beverage Market Increased by 1.2% in 2010, Beverage Marketing Corporation [Link]
Marketing Corporation. [Link] Accessed March 17, 2011. ↵

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Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.
3.10: Water Concerns by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original
source: [Link]

8.10.3 [Link]
8.11: Popular Beverage Choices
Caffeine
Caffeine is a chemical called xanthine found in the seeds, leaves, and fruit of many plants, where it acts as a natural pesticide. It is
the most widely consumed psychoactive substance and is such an important part of many people’s lives that they might not even
think of it as a drug. Up to 90 percent of adults around the world use it on a daily basis. According to both the FDA and the
American Medical Association the moderate use of caffeine is “generally recognized as safe.” It is considered a legal psychoactive
drug and, for the most part, is completely unregulated.

Typical Doses and Dietary Sources

What is a “moderate intake” of caffeine? Caffeine intakes are described in the following manner:
Low–moderate intake. 130–300 milligrams per day
Moderate intake. 200–300 milligrams per day
High intake. 400 or more milligrams per day
The average caffeine consumption for American adults is considered moderate at 280 milligrams per day, although it is not
uncommon for people to consume up to 600 milligrams per day. This works out to almost 4 ½ cups of coffee per day. The bitter
taste of caffeine is palatable for many and coffee is the most readily available source of it, accounting for 70 percent of daily
caffeine consumption. The second readily available source of caffeine is soft drinks, delivering 16 percent of daily caffeine. (In this
case, the bitter caffeine taste is usually masked by a large amount of added sugar.) Tea is the third common source of caffeine, at 12
percent.
Just how much caffeine is there in a cup of coffee? It varies. The caffeine content of an average cup of coffee can range from 102 to
200 milligrams, and the range for tea is 40 to 120 milligrams. Table provides useful information on the levels of caffeine
found in common beverages. When estimating your total caffeine consumption remember it’s not only in beverages, but also some
foods and medicine.
Table : Caffeine Content in Various Beverages and Foods

8.11.1 [Link]
 Beverage/Food Milligrams

Starbucks Grande Coffee (16 oz.) 380

Plain brewed coffee (8 oz.) 102–200

Espresso (1 oz.) 30–90

Plain, decaffeinated coffee (8 oz.) 3–12

Tea, brewed (8 oz.) 40–120

Green tea (8 oz.) 25–40

Coca-Cola Classic (12 oz.) 35

Dr. Pepper (12 oz.) 44

Jolt Cola (12 oz.) 72

Mountain Dew (12 oz.) 54

Mountain Dew, MDX (12 oz.) 71

Pepsi-Cola (12 oz.) 38

Red Bull (8.5 oz.) 80

Full Throttle (16 oz.) 144

Monster Energy (16 oz.) 160

Spike Shooter (8.4 oz.) 300

Source: [Link]. [Link] Accessed October 2, 2011.

Health Benefits
The most renowned effects of caffeine on the body are increased alertness and delay of fatigue and sleep. How does caffeine
stimulate the brain? Caffeine is chemically similar to a chemical in our brains (adenosine). Caffeine interacts with adenosine’s
specific protein receptor. It blocks the actions of the adenosine, and affects the levels of signaling molecules in the brain, leading to
an increase in energy metabolism. At the molecular level, caffeine stimulates the brain, increasing alertness and causing a delay of
fatigue and sleep. At high doses caffeine stimulates the motor cortex of the brain and interferes with the sleep-wake cycle, causing
side effects such as shakiness, anxiety, and insomnia. People’s sensitivity to the adverse effects of caffeine varies and some people
develop side effects at much lower doses. The many effects caffeine has on the brain do not diminish with habitual drinking of
caffeinated beverages.

Tools for Change

Consuming caffeine in the evening and in the middle of the night will help keep you awake to study for an exam, but it will not
enhance your performance on the next day’s test if you do not get enough sleep. Drink caffeinated beverages in moderation at any
time of the day or evening to increase alertness (if you are not sensitive to caffeine’s adverse effects), but get the recommended
amount of sleep.
It is important to note that caffeine has some effects on health that are either promoted or masked by the other beneficial chemicals
found in coffee and tea. This means that when assessing the benefits and consequences of your caffeine intake, you must take into
account how much caffeine in your diet comes from coffee and tea versus how much you obtain from soft drinks.

8.11.2 [Link]
Figure : Photo by Jeremy Ricketts on [Link] / CC0
There is scientific evidence supporting that higher consumption of caffeine, mostly in the form of coffee, substantially reduces the
risk for developing Type 2 diabetes and Parkinson’s disease. There is a lesser amount of evidence suggesting increased coffee
consumption lowers the risk of heart attacks in both men and women, and strokes in women. In smaller population studies,
decaffeinated coffee sometimes performs as well as caffeinated coffee, bringing up the hypothesis that there are beneficial
chemicals in coffee other than caffeine that play larger roles in the health benefits of coffee. A review of fifteen epidemiological
studies in The Journal of the American Medical Association proposes that habitual coffee consumption reduces the risk of Type 2
diabetes.[1] The risk reduction was 35 percent for those who consumed greater than 6–7 cups of coffee per day and was 28 percent
for those who consumed 4–5 cups daily. These groups were compared with people who consumed less than 2 cups of coffee per
day.
Parkinson’s disease is an illness of the central nervous system causing many disorders of movement. Research scientists in Hawai‘i
found an inverse relationship between caffeine intake and the incidence of Parkinson’s disease. Men who did not consume coffee
had a five times more likely chance of Parkinson’s disease than men who consumed more than 3 cups of coffee daily.[2]
In this study other caffeine sources, such as soft drinks and tea, were also associated with a reduced risk of Parkinson’s disease. A
review of several studies, published in the Journal of Alzheimer’s Disease, has reaffirmed that caffeine intake may reduce the risk
of Parkinson’s disease in both men and women.[3] This review also took into consideration caffeine obtained from dietary sources
other than caffeine, though the data on these is not as extensive or as strong as for coffee. There is also some scientific evidence
that drinking coffee is linked to a much lower risk for dementia and Alzheimer’s disease.[4]

Health Consequences
The acute adverse health effects of caffeine ingestion are anxiety, shakiness, and sleep deprivation. On a more chronic basis, some
scientific reports suggest that higher caffeine intake is linked to negative effects on heart health and increased cardiovascular
disease; although at this point most data suggests caffeine does not significantly increase either. A comprehensive review published
in the American Journal of Clinical Nutrition reports that caffeine induces a modest increase in blood pressure lasting less than
three hours in people with hypertension, but there is no evidence that habitual coffee consumption increases blood pressure long-
term or increases the risk for cardiovascular disease.[5]
There is no good evidence that chronic caffeine exposure increases blood pressure chronically in people without hypertension.
Some have hypothesized that caffeine elevates calcium excretion and therefore could potentially harm bones. The scientific
consensus at this time is that caffeine minimally affects calcium levels and intake is not associated with any increased risk for
osteoporosis or the incidence of fractures in most women. Although the effect of caffeine on calcium excretion is small,
postmenopausal women with risk factors for osteoporosis may want to make sure their dietary caffeine intake is low or moderate
and not excessive.

8.11.3 [Link]
The Caffeine Myth
A diuretic refers to any substance that elevates the normal urine output above that of drinking water. Caffeinated beverages are
commonly believed to be dehydrating due to their diuretic effect, but results from scientific studies do not support that caffeinated
beverages increase urine output more so than water. This does not mean that consuming caffeinated beverages does not affect urine
output, but rather that it does not increase urine output more than water does. Thus, caffeinated beverages are considered a source
of hydration similar to water.

Sports Drinks
Scientific studies under certain circumstances show that consuming sports drinks (instead of plain water) during high-intensity
exercise lasting longer than one hour significantly enhances endurance, and some evidence indicates it additionally enhances
performance. There is no consistent evidence that drinking sports drinks instead of plain water enhances endurance or performance
in individuals exercising less than one hour and at low to moderate intensities. A well-concocted sports drink contains sugar, water,
and sodium in the correct proportions so that hydration is optimized. The sugar is helpful in maintaining blood-glucose levels
needed to fuel muscles, the water keeps an athlete hydrated, and the sodium enhances fluid absorption and replaces some of that
lost in sweat. The American College of Sports Medicine states that the goal of drinking fluids during exercise is to prevent
dehydration, which compromises performance and endurance.
The primary source of water loss during intense physical activity is sweat. Perspiration rates are variable and dependent on many
factors including body composition, humidity, temperature, and type of exercise. The hydration goal for obtaining optimal
endurance and performance is to replace what is lost, not to over-hydrate. A person’s sweating rate can be approximated by
measuring weight before and after exercise—the difference in weight will be the amount of water weight you lost.
The primary electrolyte lost in sweat is sodium. One liter of sweat can contain between 1,000–2,000 milligrams of sodium.
Potassium, magnesium, and calcium are also lost, but in much lower amounts. If you are exercising at high intensity for greater
than ninety minutes, it is important to replace sodium as well as water. This can be partly accomplished by consuming a sports
drink. The highest content of sodium in commercial sports drinks is approximately 450 milligrams per liter and thus will not
replace all lost sodium unless a person drinks several liters. This is NOT recommended, as water intoxication not only
compromises performance, but may also be deadly. The sodium in sports drinks enhances fluid absorption so that rehydration is
more efficiently accomplished. If you are not exercising for more than ninety minutes at a high intensity, dietary intake of sodium
and other electrolytes should be sufficient for replacing lost electrolytes.

Who Needs Sports Drinks?

Children and adult athletes exercising for more than one hour at high-intensity (tennis, rowing, rugby, soccer, etc.) may benefit
endurance-wise and possibly performance-wise from consuming a sports drink rather than water. However, consuming sports
drinks provides no benefit over water to endurance, performance, or exercise recovery for those exercising less than an hour. In
fact, as with all other sugary drinks containing few to no nutrients, they are only another source of calories. Drinking sports drinks
when you are doing no exercise at all is not recommended.

Sports Drink Alternatives

Instead of a sports drink, you can replenish lost fluids and obtain energy and electrolytes during exercise by drinking plain water
and eating a sports bar or snack that contains carbohydrates, protein, and electrolytes. Post-exercise, low-fat milk has been
scientifically shown to be just as effective as a sports drink as a rehydration beverage and it is more nutrient-dense, containing
carbohydrates, protein, and electrolytes, in addition to other vitamins.

The Bottom Line

Sports drinks consumed in excess by athletes or used by non-athletes simply are another source of added sugars, and thus extra
calories, in the diet and provide no performance, exercise recovery or health benefit.
An interactive or media element has been excluded from this version of the text. You can view it online here:
[Link]/humannutrition2/?p=165

8.11.4 [Link]
Resources
1. van Dam R M, Hu FB. (2005). Coffee Consumption and Risk of Type 2 Diabetes: A Systematic Review. Journal of the
American Medical Association, 294(1), 97–104. [Link] Accessed
September 22, 2017. ↵
2. Ross GW, et al. (2000). Association of Coffee and Caffeine Intake with the Risk of Parkinson’s Disease. Journal of the
American Medical Association, 283(20), 2674–79. [Link] Accessed
September 22, 2017. ↵
3. Costa J, et al. (2010). Caffeine Exposure and the Risk of Parkinson’s Disease: A Systematic Review and Meta-Analysis of
Observational Studies. Journal of Alzheimer's disease, 20, S221–38. [Link] Accessed
September 22, 2017. ↵
4. Patil H, Lavie CJ, O’Keefe JH . (2011). Cuppa Joe: Friend or Foe? Effects of Chronic Coffee Consumption on Cardiovascular
and Brain Health. Missouri Medical, 108(6), 431–8. [Link] Accessed September 22,
2017. ↵
5. Mesas AE, et al. (2011). The Effect of Coffee on Blood Pressure and Cardiovascular Disease in Hypertensive Individuals: A
Systematic Review and Meta-Analysis. American Journal of Clinical Nutrition, 94(4), 1113–26.
[Link] Accessed September 22, 2017. ↵

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LibreTexts platform.
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Original source: [Link]

8.11.5 [Link]
 CHAPTER OVERVIEW

9: Major Minerals
Learning Objectives
By the end of this chapter you will be able to:
Describe the functional role, intake recommendations and sources of major minerals

9.1: Introduction to Major Minerals

9.2: Calcium
9.2.1: Bone Structure and Function
9.2.2: Bone Mineral Density is an Indicator of Bone Health
9.2.3: Micronutrients Essential for Bone Health- Calcium and Vitamin D
9.2.4: Osteoporosis
[Link]: Risk Factors for Osteoporosis
[Link]: Osteoporosis Prevention and Treatment
9.3: Phosphorus
9.4: Magnesium
9.5: Summary of Major Minerals

This page titled 9: Major Minerals is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper,
Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.

1
9.1: Introduction to Major Minerals
He pūko`a kani `āina
A coral reef strengthens into land.

Figure : Choy Sum by [Link] / CCO

Similarly to vitamins, minerals are essential to human health and can be obtained in our diet from different types of food. Minerals
are abundant in our everyday lives. From the soil in your front yard to the jewelry you wear on your body, we interact with
minerals constantly. There are 20 essential minerals that must be consumed in our diets to remain healthy. The amount of each
mineral found in our bodies vary greatly and therefore, so does consumption of those minerals. When there is a deficiency in an
essential mineral, health problems may arise.
Major minerals are classified as minerals that are required in the diet each day in amounts larger than 100 milligrams. These
include sodium, potassium, chloride, calcium, phosphorus, magnesium, and sulfur. These major minerals can be found in various
foods. For example, in Guam, the major mineral, calcium, is consumed in the diet not only through dairy, a common source of
calcium, but also through through the mixed dishes, desserts and vegetables that they consume. Consuming a varied diet
significantly improves an individual’s ability to meet their nutrient needs. [1]

9.1.1 [Link]
 Figure : The Major Minerals. Image by Allison Calabrese / CC BY 4.0

Bioavailability
Minerals are not as efficiently absorbed as most vitamins and so the bioavailability of minerals can be very low. Plant-based foods
often contain factors, such as oxalate and phytate, that bind to minerals and inhibit their absorption. In general, minerals are better
absorbed from animal-based foods. In most cases, if dietary intake of a particular mineral is increased, absorption will decrease.
Some minerals influence the absorption of others. For instance, excess zinc in the diet can impair iron and copper absorption.
Conversely, certain vitamins enhance mineral absorption. For example, vitamin C boosts iron absorption, and vitamin D boosts
calcium and magnesium absorption. As is the case with vitamins, certain gastrointestinal disorders and diseases, such as Crohn’s
disease and kidney disease, as well as the aging process, impair mineral absorption, putting people with
malabsorption conditions and the elderly at higher risk for mineral deficiencies.

References
1. Pobocik RS, Trager A, Monson LM. (2008). Dietary Patterns and Food Choices of a Population Sample of Adults on Guam.
Asia Pacific Journal of Clinical Nutrition., 17(1), 94-100. [Link] Accessed
February 16, 2018. ↵

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Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
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4.0. Original source: [Link]

9.1.2 [Link]
9.2: Calcium
Calcium’s Functional Roles
Calcium is the most abundant mineral in the body and greater than 99 percent of it is stored in bone tissue. Although only 1 percent
of the calcium in the human body is found in the blood and soft tissues, it is here that it performs the most critical functions. Blood
calcium levels are rigorously controlled so that if blood levels drop the body will rapidly respond by stimulating bone resorption,
thereby releasing stored calcium into the blood. Thus, bone tissue sacrifices its stored calcium to maintain blood calcium levels.
This is why bone health is dependent on the intake of dietary calcium and also why blood levels of calcium do not always
correspond to dietary intake.
Calcium plays a role in a number of different functions in the body like bone and tooth formation. The most well-known calcium
function is to build and strengthen bones and teeth. Recall that when bone tissue first forms during the modeling or remodeling
process, it is unhardened, protein-rich osteoid tissue. In the osteoblast-directed process of bone mineralization, calcium phosphates
(salts) are deposited on the protein matrix. The calcium salts typically make up about 65 percent of bone tissue. When your diet is
calcium deficient, the mineral content of bone decreases causing it to become brittle and weak. Thus, increased calcium intake
helps to increase the mineralized content of bone tissue. Greater mineralized bone tissue corresponds to a greater BMD, and to
greater bone strength. The remaining calcium plays a role in nerve impulse transmission by facilitating electrical impulse
transmission from one nerve cell to another. Calcium in muscle cells is essential for muscle contraction because the flow of calcium
ions are needed for the muscle proteins (actin and myosin) to interact. Calcium is also essential in blood clotting by activating
clotting factors to fix damaged tissue.
In addition to calcium’s four primary functions calcium has several other minor functions that are also critical for maintaining
normal physiology. For example, without calcium, the hormone insulin could not be released from cells in the pancreas and
glycogen could not be broken down in muscle cells and used to provide energy for muscle contraction.

Maintaining Calcium Levels

Because calcium performs such vital functions in the body, blood calcium level is closely regulated by the hormones parathyroid
hormone (PTH), calcitriol, and calcitonin. When blood calcium levels are low, PTH is secreted to increase blood calcium levels via
three different mechanisms. First, PTH stimulates the release of calcium stored in the bone. Second, PTH acts on kidney cells to
increase calcium reabsorption and decrease its excretion in the urine. Third, PTH stimulates enzymes in the kidney that activate
vitamin D to calcitriol. Calcitriol is the active hormone that acts on the intestinal cells and increases dietary calcium absorption.
When blood calcium levels become too high, the hormone calcitonin is secreted by certain cells in the thyroid gland and PTH
secretion stops. At higher nonphysiological concentrations, calcitonin lowers blood calcium levels by increasing calcium excretion
in the urine, preventing further absorption of calcium in the gut and by directly inhibiting bone resorption.

9.2.1 [Link]
 Figure : Maintaining Blood Calcium Levels. Image by Allison
Calabrese / CC BY 4.0

Other Health Benefits of Calcium in the Body

Besides forming and maintaining strong bones and teeth, calcium has been shown to have other health benefits for the body,
including:
Cancer. The National Cancer Institute reports that there is enough scientific evidence to conclude that higher intakes of calcium
decrease colon cancer risk and may suppress the growth of polyps that often precipitate cancer. Although higher calcium
consumption protects against colon cancer, some studies have looked at the relationship between calcium and prostate cancer
and found higher intakes may increase the risk for prostate cancer; however the data is inconsistent and more studies are needed
to confirm any negative association.
Blood pressure. Multiple studies provide clear evidence that higher calcium consumption reduces blood pressure. A review of
twenty-three observational studies concluded that for every 100 milligrams of calcium consumed daily, systolic blood pressure
is reduced 0.34 millimeters of mercury (mmHg) and diastolic blood pressure is decreased by 0.15 mmHg.[1]
Cardiovascular health. There is emerging evidence that higher calcium intakes prevent against other risk factors for
cardiovascular disease, such as high cholesterol and obesity, but the scientific evidence is weak or inconclusive.
Kidney stones. Another health benefit of a high-calcium diet is that it blocks kidney stone formation. Calcium inhibits the
absorption of oxalate, a chemical in plants such as parsley and spinach, which is associated with an increased risk for
developing kidney stones. Calcium’s protective effects on kidney stone formation occur only when you obtain calcium from
dietary sources. Calcium supplements may actually increase the risk for kidney stones in susceptible people.

9.2.2 [Link]
 Figure : Calcium’s Effect on Aging. Image by James Heilman, MD / CC BY-
SA 3.0
Calcium inadequacy is most prevalent in adolescent girls and the elderly. Proper dietary intake of calcium is critical for proper bone
health.
Despite the wealth of evidence supporting the many health benefits of calcium (particularly bone health), the average American
diet falls short of achieving the recommended dietary intakes of calcium. In fact, in females older than nine years of age, the
average daily intake of calcium is only about 70 percent of the recommended intake. Here we will take a closer look at particular
groups of people who may require extra calcium intake.
Adolescent teens. A calcium-deficient diet is common in teenage girls as their dairy consumption often considerably drops
during adolescence.
Amenorrheic women and the “female athlete triad“. Amenorrhea refers to the absence of a menstrual cycle. Women who fail
to menstruate suffer from reduced estrogen levels, which can disrupt and have a negative impact on the calcium balance in their
bodies. The “female athlete triad” is a combination of three conditions characterized by amenorrhea, disrupted eating patterns,
and osteoporosis. Exercise-induced amenorrhea and anorexia nervosa-related amenorrhea can decrease bone mass.[2][3] In
female athletes, as well as active women in the military, low BMD, menstrual irregularities, and individual dietary habits
together with a history of previous stress issues are related to an increased susceptibility to future stress fractures.[4][5]
The elderly. As people age, calcium bioavailability is reduced, the kidneys lose their capacity to convert vitamin D to its most
active form, the kidneys are no longer efficient in retaining calcium, the skin is less effective at synthesizing vitamin D, there
are changes in overall dietary patterns, and older people tend to get less exposure to sunlight. Thus the risk for calcium
inadequacy is great.[6]
Postmenopausal women. Estrogen enhances calcium absorption. The decline in this hormone during and after menopause puts
postmenopausal women especially at risk for calcium deficiency. Decreases in estrogen production are responsible for an
increase in bone resorption and a decrease in calcium absorption. During the first years of menopause, annual decreases in bone
mass range from 3–5 percent. After age sixty-five, decreases are typically less than 1 percent.[7]
Lactose-intolerant people. Groups of people, such as those who are lactose intolerant, or who adhere to diets that avoid dairy
products, may not have an adequate calcium intake.

9.2.3 [Link]
 Vegans. Vegans typically absorb reduced amounts of calcium because their diets favor plant-based foods that contain oxalates
and phytates.[8]
In addition, because vegans avoid dairy products, their overall consumption of calcium-rich foods may be less.
If you are lactose intolerant, have a milk allergy, are a vegan, or you simply do not like dairy products, remember that there are
many plant-based foods that have a good amount of calcium and there are also some low-lactose and lactose-free dairy products on
the market.

Calcium Supplements: Which One to Buy?

Many people choose to fulfill their daily calcium requirements by taking calcium supplements. Calcium supplements are sold
primarily as calcium carbonate, calcium citrate, calcium lactate, and calcium phosphate, with elemental calcium contents of about
200 milligrams per pill. It is important to note that calcium carbonate requires an acidic environment in the stomach to be used
effectively. Although this is not a problem for most people, it may be for those on medication to reduce stomach-acid production or
for the elderly who may have a reduced ability to secrete acid in the stomach. For these people, calcium citrate may be a better
choice. Otherwise, calcium carbonate is the cheapest. The body is capable of absorbing approximately 30 percent of the calcium
from these forms.

Beware of Lead
There is public health concern about the lead content of some brands of calcium supplements, as supplements derived from natural
sources such as oyster shell, bone meal, and dolomite (a type of rock containing calcium magnesium carbonate) are known to
contain high amounts of lead. In one study conducted on twenty-two brands of calcium supplements, it was proven that eight of the
brands exceeded the acceptable limit for lead content. This was found to be the case in supplements derived from oyster shell and
refined calcium carbonate. The same study also found that brands claiming to be lead-free did, in fact, show very low lead levels.
Because lead levels in supplements are not disclosed on labels, it is important to know that products not derived from oyster shell
or other natural substances are generally low in lead content. In addition, it was also found that one brand did not disintegrate as is
necessary for absorption, and one brand contained only 77 percent of the stated calcium content.[9]

Diet, Supplements, and Chelated Supplements

In general, calcium supplements perform to a lesser degree than dietary sources of calcium in providing many of the health benefits
linked to higher calcium intake. This is partly attributed to the fact that dietary sources of calcium supply additional nutrients with
health-promoting activities. It is reported that chelated forms of calcium supplements are easier to absorb as the chelation process
protects the calcium from oxalates and phytates that may bind with the calcium in the intestines. However, these are more
expensive supplements and only increase calcium absorption up to 10 percent. In people with low dietary intakes of calcium,
calcium supplements have a negligible benefit on bone health in the absence of a vitamin D supplement. However, when calcium
supplements are taken along with vitamin D, there are many benefits to bone health: peak bone mass is increased in early
adulthood, BMD is maintained throughout adulthood, the risk of developing osteoporosis is reduced, and the incidence of fractures
is decreased in those who already had osteoporosis. Calcium and vitamin D pills do not have to be taken at the same time for
effectiveness. But remember that vitamin D has to be activated and in the bloodstream to promote calcium absorption. Thus, it is
important to maintain an adequate intake of vitamin D.

The Calcium Debate

A recent study published in the British Medical Journal reported that people who take calcium supplements at doses equal to or
greater than 500 milligrams per day in the absence of a vitamin D supplement had a 30 percent greater risk for having a heart
attack.[10]
Does this mean that calcium supplements are bad for you? If you look more closely at the study, you will find that 5.8 percent of
people (143 people) who took calcium supplements had a heart attack, but so did 5.5 percent of the people (111) people who took
the placebo. While this is one study, several other large studies have not shown that calcium supplementation increases the risk for
cardiovascular disease. While the debate over this continues in the realm of science, we should focus on the things we do know:
1. There is overwhelming evidence that diets sufficient in calcium prevent osteoporosis and cardiovascular disease.

9.2.4 [Link]
2. People with risk factors for osteoporosis are advised to take calcium supplements if they are unable to get enough calcium in
their diet. The National Osteoporosis Foundation advises that adults age fifty and above consume 1,200 milligrams of calcium
per day. This includes calcium both from dietary sources and supplements.
3. Consuming more calcium than is recommended is not better for your health and can prove to be detrimental. Consuming too
much calcium at any one time, be it from diet or supplements, impairs not only the absorption of calcium itself, but also the
absorption of other essential minerals, such as iron and zinc. Since the GI tract can only handle about 500 milligrams of calcium
at one time, it is recommended to have split doses of calcium supplements rather than taking a few all at once to get the RDA of
calcium.

Dietary Reference Intake for Calcium

The recommended dietary allowances (RDA) for calcium are listed in Table 10.1. The RDA is elevated to 1,300 milligrams per day
during adolescence because this is the life stage with accelerated bone growth. Studies have shown that a higher intake of calcium
during puberty increases the total amount of bone tissue that accumulates in a person. For women above age fifty and men older
than seventy-one, the RDAs are also a bit higher for several reasons including that as we age, calcium absorption in the gut
decreases, vitamin D3 activation is reduced, and maintaining adequate blood levels of calcium is important to prevent an
acceleration of bone tissue loss (especially during menopause). Currently, the dietary intake of calcium for females above age nine
is, on average, below the RDA for calcium. The Institute of Medicine (IOM) recommends that people do not consume over 2,500
milligrams per day of calcium as it may cause adverse effects in some people.
Table : Dietary Reference Intakes for Calcium
Age Group RDA (mg/day) UL (mg/day)

Infants (0–6 months) 200* –

Infants (6–12 months) 260* –

Children (1–3 years) 700 2,500

Children (4–8 years) 1,000 2,500

Children (9–13 years) 1,300 2,500

Adolescents (14–18 years) 1,300 2,500

Adults (19–50 years) 1,000 2,500

Adult females (50–71 years) 1,200 2,500

Adults, male & female (> 71 years) 1,200 2,500

* denotes Adequate Intake

Source: Ross AC, Manson JE, et al. The 2011 Report on Dietary Reference Intakes for Calcium and Vitamin D from the Institute of
Medicine: What Clinicians Need to Know. J Clin Endocrinol Metab. 2011; 96(1), 53–8.
[Link] Accessed October 10, 2017.

Dietary Sources of Calcium

In the typical American diet, calcium is obtained mostly from dairy products, primarily cheese. A slice of cheddar or Swiss cheese
contains just over 200 milligrams of calcium. One cup of nonfat milk contains approximately 300 milligrams of calcium, which is
about a third of the RDA for calcium for most adults. Foods fortified with calcium such as cereals, soy milk, and orange juice also
provide one third or greater of the calcium RDA. Although the typical American diet relies mostly on dairy products for obtaining
calcium, there are other good non-dairy sources of calcium.

9.2.5 [Link]
  Tools for Change

If you need to increase calcium intake, are a vegan, or have a food allergy to dairy products, it is helpful to know that there are
some plant-based foods that are high in calcium. Tofu (made with calcium sulfate), turnip greens, mustard greens, and chinese
cabbage are good sources. For a list of non-dairy sources you can find the calcium content for thousands of foods by visiting
the USDA National Nutrient Database ([Link] When obtaining your calcium from a
vegan diet, it is important to know that some plant-based foods significantly impair the absorption of calcium. These include
spinach, Swiss chard, rhubarb, beets, cashews, and peanuts. With careful planning and good selections, you can ensure that you
are getting enough calcium in your diet even if you do not drink milk or consume other dairy products.

Calcium Bioavailability
In the small intestine, calcium absorption primarily takes place in the duodenum (first section of the small intestine) when intakes
are low, but calcium is also absorbed passively in the jejunum and ileum (second and third sections of the small intestine),
especially when intakes are higher. The body doesn’t completely absorb all the calcium in food. Interestingly, the calcium in some
vegetables such as kale, brussel sprouts, and bok choy is better absorbed by the body than are dairy products. About 30 percent of
calcium is absorbed from milk and other dairy products.
The greatest positive influence on calcium absorption comes from having an adequate intake of vitamin D. People deficient in
vitamin D absorb less than 15 percent of calcium from the foods they eat. The hormone estrogen is another factor that enhances
calcium bioavailability. Thus, as a woman ages and goes through menopause, during which estrogen levels fall, the amount of
calcium absorbed decreases and the risk for bone disease increases. Some fibers, such as inulin, found in jicama, onions, and garlic,
also promote calcium intestinal uptake.
Chemicals that bind to calcium decrease its bioavailability. These negative effectors of calcium absorption include the oxalates in
certain plants, the tannins in tea, phytates in nuts, seeds, and grains, and some fibers. Oxalates are found in high concentrations in
spinach, parsley, cocoa, and beets. In general, the calcium bioavailability is inversely correlated to the oxalate content in foods.
High-fiber, low-fat diets also decrease the amount of calcium absorbed, an effect likely related to how fiber and fat influence the
amount of time food stays in the gut. Anything that causes diarrhea, including sickness, medications, and certain symptoms related
to old age, decreases the transit time of calcium in the gut and therefore decreases calcium absorption. As we get older, stomach
acidity sometimes decreases, diarrhea occurs more often, kidney function is impaired, and vitamin D absorption and activation is
compromised, all of which contribute to a decrease in calcium bioavailability.
Table : Calcium Content and Bioavailability of Various Foods

9.2.6 [Link]
 Estimated
Food Serving Calcium (mg) Absorption (%) Calcium % Daily Value1 % Daily Value2
Absorbed (mg)

Yogurt, low fat 8.5 oz. 300 32 96 7.4 9.6

Mozzarella, part
1.5 oz. 333 32 107 8.2 10.7
skim

Sardines, canned
3 oz. 325 27 88 6.8 8.8
with bones

Cheddar Cheese 1.5 oz. 303 32 97 7.5 9.7

Milk, nonfat 8.5 oz. 300 32 96 7.4 9.6

Soymilk,
8.5 oz. 300 24 72 5.5 7.2
calcium fortified

Orange juice,
8.5 oz. 300 36 109 8.4 10.9
calcium fortified

Tofu, firm, made

with calcium ½ c. 258 31 80 6.2 8.0
sulfate

Salmon, canned
3 oz. 181 27 49 3.8 4.9
with bones

Turnip Greens ½ c. 99 52 51 4.0 5.1

Kale, cooked 1 c. 94 49 30 2.3 3.0

Vanilla Ice
½ c. 84 32 27 2.1 2.7
Cream, light

Broccoli, cooked 1 c. 35 61 19 1.5 1.9

Cauliflower,
1 c. 10 69 6.9 0.5 0.7
cooked

Red Beans,
1 c. 41 24 9.84 0.8 1.0
cooked

1
Based on DV = 1000 mg
2
Based on DV = 1300 mg
Source: Office of Dietary Supplements. (2020, March 26). Calcium. [Link] and
Titchenal, C. A., & Dobbs, J. (2007). A system to assess the quality of food sources of calcium. Journal of Food Composition and
Analysis, 20(8), 717–724. doi: 10.1016/[Link].2006.04.013

References
1. Birkett NJ. (1998). Comments on a Meta-Analysis of the Relation between Dietary Calcium Intake and Blood Pressure.
American Journal of Epidemiology, 148(3), 223–28. [Link]/content/148/3/[Link]. Accessed October 10, 2017.
↵
2. Drinkwater B, Bruemner B, Chesnut C. (1990). Menstrual History As a Determinant of Current Bone Density in Young
Athletes. The Journal of the American Medical Association, 263(4), 545–8. [Link]
dopt=Abstract. . Accessed November 22, 2017. ↵

9.2.7 [Link]
 3. Marcus R. et al. (1985). Menstrual Function and Bone Mass in Elite Women Distance Runners: Endocrine and Metabolic
Features. The Annuals of Internal Medicine, 102(2), 58–63. [Link]
Accessed November 22, 2017. ↵
4. Nattiv A. Stress (2000). Fractures and Bone Health in Track and Field Athletes. The Journal of Science & Medicine in Sport,
3(3), 268–79. [Link] November 22, 2017. ↵
5. Johnson AO, et al. (1993). Correlation of Lactose Maldigestion, Lactose Intolerance, and Milk Intolerance. American Journal of
Clinical Nutrition, 57(3), 399–401. [Link] Accessed November 22,
2017. ↵
6. Calcium and Vitamin D in the Elderly. International Osteoporosis Foundation. [Link]/patients-public/about-
osteoporosis/prevention /nutrition/[Link]. Published 2012. Accessed November 22, 2017. ↵
7. Daniels CE. (2000). Estrogen Therapy for Osteoporosis Prevention in Postmenopausal Women. National Institute of Health:
Pharmacy. Update March/April 2000. ↵
8. Dietary Reference Intakes for Calcium and Vitamin [Link] and Nutrition Board, Institute of Medicine. Washington, DC:
National Academy Press. 2010. ↵
9. Ross EA, Szabo NJ, Tebbett IR. (2000). Lead Content of Calcium Supplements. The Journal of the American Medical
Association, 284, 1425–33. ↵
10. Bolland MJ. et al. (2010). Effect of Calcium Supplements on Risk of Myocardial Infarction and Cardiovascular Events: Meta-
Analysis. British Medical Journal, 341(c3691). ↵

This page titled 9.2: Calcium is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper, Marie
Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.
10.2: Calcium by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original source:
[Link]

9.2.8 [Link]
9.2.1: Bone Structure and Function
Learning Objectives
Explain the process of bone remodeling and explain why bones are living tissues.

Your bones are stronger than reinforced concrete. Bone tissue is a composite of fibrous collagen strands that resemble the steel
rebar in concrete and a hardened mineralized matrix that contains large amounts of calcium, just like concrete. But this is where the
similarities end. Bone outperforms reinforced concrete by several orders of magnitude in compression and tension strength tests.
Why? The microarchitecture of bone is complex and built to withstand extreme forces. Moreover, bone is a living tissue that is
continuously breaking down and forming new bone to adapt to mechanical stresses.

Before you disbelieve - know your body -…

-…

Video : The Human Body: Bone Strength. This video is a dramatic

demonstration of bone strength. ([Link]
v=FlATeMqTH2g).

Why Is the Skeletal System Important?

The human skeleton consists of 206 bones and other connective tissues called ligaments, tendons, and cartilage. Ligaments connect
bones to other bones, tendons connect bones to muscles, and cartilage provides bones with more flexibility and acts as a cushion in
the joints between bones. The skeleton’s many bones and connective tissues allow for multiple types of movement such as typing
and running. The skeleton provides structural support and protection for all the other organ systems in the body. The skull, or
cranium, is like a helmet and protects the eyes, ears, and brain. The ribs form a cage that surrounds and protects the lungs and heart.
In addition to aiding in movement, protecting organs, and providing structural support, red and white blood cells and platelets are
synthesized in bone marrow. Another vital function of bones is that they act as a storage depot for minerals such as calcium,
phosphorous, and magnesium. Although bone tissue may look inactive at first glance, at the microscopic level you will find that
bones are continuously breaking down and reforming. Bones also contain a complex network of canals, blood vessels, and nerves
that allow for nutrient transport and communication with other organ systems.

[Link] [Link]
 Figure : The human skeleton contains 206 bones. It is divided into two main
parts, the axial and appendicular. © Networkgraphics

Bone Anatomy and Structure

To optimize bone health through nutrition, it is important to understand bone anatomy. The skeleton is composed of two main parts,
the axial and the appendicular parts. The axial skeleton consists of the skull, vertebral column, and rib cage, and is composed of
eighty bones. The appendicular skeleton consists of the shoulder girdle, pelvic girdle, and upper and lower extremities and is
composed of 126 bones. Bones are also categorized by size and shape. There are four types of bone: long bones, short bones, flat
bones, and irregular bones. The longest bone in your body is the femur (or “thigh” bone), which extends from your hip to your
knee. It is a long bone and functions to support your weight as you stand, walk, or run. Your wrist is composed of eight irregular-
shaped bones, which allow for the intricate movements of your hands. Your twelve ribs on each side of your body are curved flat
bones that protect your heart and lungs. Thus, the bones’ different sizes and shapes allow for their different functions.

[Link] [Link]
 Figure : The Arrangement of Bone Tissues. Bone is
composed of organized living tissues. © Networkgraphics
Bones are composed of approximately 65 percent inorganic material known as mineralized matrix. This mineralized matrix consists
of mostly crystallized hydroxyapatite. The bone’s hard crystal matrix of bone tissue gives it its rigid structure. The other 35 percent
of bone is organic material, most of which is the fibrous protein, collagen. The collagen fibers are networked throughout bone
tissue and provide it with flexibility and strength. The bones’ inorganic and organic materials are structured into two different tissue
types. There is spongy bone, also called trabecular or cancellous bone, and compact bone, also called cortical bone (Figure ).
The two tissue types differ in their microarchitecture and porosity. Trabecular bone is 50 to 90 percent porous and appears as a
lattice-like structure under the microscope. It is found at the ends of long bones, in the cores of vertebrae, and in the pelvis.
Trabecular bone tissue makes up about 20 percent of the adult skeleton. The more dense cortical bone is about 10 percent porous
and it looks like many concentric circles, similar to the rings in a tree trunk, sandwiched together (Figure ). Cortical bone
tissue makes up approximately 80 percent of the adult skeleton. It surrounds all trabecular tissue and is the only bone tissue in the
shafts of long bones.

Figure : The two

basic tissue types of bones are trabecular and cortical. Trabecular (spongy) and cortical (compact) bone tissues differ in their
microarchitecture and porosity. © Networkgraphics
Bone tissue is arranged in an organized manner. A thin membrane, called the periosteum, surrounds the bone. It contains connective
tissue with many blood vessels and nerves. Lying below the periosteum is the cortical bone. In some bones, the cortical bone
surrounds the less-dense trabecular bone and the bone marrow lies within the trabecular bone, but not all bones contain trabecular
tissue or marrow.

Bone Tissues and Cells, Modeling and Remodeling

Bone tissue contains many different cell types that constantly resize and reshape bones throughout growth and adulthood. Bone
tissue cells include osteoprogenitor cells, osteoblasts, osteoclasts, and osteocytes. The osteoprogenitor cells are cells that have not
matured yet. Once they are stimulated, some will become osteoblasts, the bone builders, and others will become osteoclasts, the
cells that break bone down. Osteocytes are the most abundant cells in bone tissue. Osteocytes are star-shaped cells that are
networked throughout the bone via their long cytoplasmic arms that allow for the exchange of nutrients and other factors from
bones to the blood and lymph.

[Link] [Link]
Bone Modeling and Remodeling
During infancy, childhood, and adolescence, bones are continuously growing and changing shape through two processes called
growth (or ossification) and modeling. In fact, in the first year of life, almost 100 percent of the bone tissue in the skeleton is
replaced. In the process of modeling, bone tissue is dismantled at one site and built up at a different site. In adulthood, our bones
stop growing and modeling, but continue to go through a process of bone remodeling. In the process of remodeling, bone tissue is
degraded and built up at the same location. About 10 percent of bone tissue is remodeled each year in adults. As observed in Video
, bones adapt their structure to the forces acting upon them, even in adulthood. This phenomenon is called Wolff’s law,
which states that bones will develop a structure that is best able to resist the forces acting upon them. This is why exercising,
especially when it involves weight-bearing activities, increases bone strength.

Bone Remodeling

Video : Bone Modification. This video on bone remodeling demonstrates a bone’s adaptability to mechanical stresses.
[Link]
The first step in bone remodeling is osteocyte activation (Figure ). Osteocytes detect changes in mechanical forces, calcium
homeostasis, or hormone levels. In the second step, osteoclasts are recruited to the site of the degradation. Osteoclasts are large
cells with a highly irregular ruffled membrane. These cells fuse tightly to the bone and secrete hydrogen ions, which acidify the
local environment and dissolve the minerals in the bone tissue matrix. This process is called bone resorption and resembles pit
excavation. Our bodies excavate pits in our bone tissue because bones act as storehouses for calcium and other minerals. Bones
supply these minerals to other body tissues as the demand arises. Bone tissue also remodels when it breaks so that it can repair
itself. Moreover, if you decide to train to run a marathon your bones will restructure themselves by remodeling to better able
sustain the forces of their new function.

[Link] [Link]
 Figure : Bone remodeling occurs in four steps:
activation, osteoclast resorption, surface preparation, and building new bone tissue. © Networkgraphics
After a certain amount of bone is excavated, the osteoclasts begin to die and bone resorption stops. In the third step of bone
remodeling, the site is prepared for building. In this stage, sugars and proteins accumulate along the bone’s surface, forming a
cement line which acts to form a strong bond between the old bone and the new bone that will be made. These first three steps take
approximately two to three weeks to complete. In the last step of bone remodeling, osteoblasts lay down new osteoid tissue that
fills up the cavities that were excavated during the resorption process. Osteoid is bone matrix tissue that is composed of proteins
such as collagen and is not mineralized yet. To make collagen, vitamin C is required. A symptom of vitamin C deficiency (known
as scurvy) is bone pain, which is caused by diminished bone remodeling. After the osteoid tissue is built up, the bone tissue begins
to mineralize. The last step of bone remodeling continues for months, and for a much longer time afterward the mineralized bone is
continuously packed in a more dense fashion.
Thus, we can say that bone is a living tissue that continually adapts itself to mechanical stress through the process of remodeling.
For bone tissue to remodel certain nutrients such as calcium, phosphorus, magnesium, fluoride, vitamin D, and vitamin K are
required.

Key Takeaways
The skeletal system aids in movement, provides support for and protects organs, synthesizes platelets and red and white blood cells,
and serves as a storage depot for minerals, such as calcium. The skeleton is composed of connective tissues including bones,
cartilage, tendons, and [Link] are made up of a periosteum that surrounds compact bone, which in turn surrounds
trabecular bone. Bone marrow resides within the trabecular bone. Bone tissue cells are osteoprogenitor cells, osteoblasts,
osteoclasts, and osteocytes. Bone is a living tissue that adapts to mechanical stress via the remodeling process. Bone remodeling is
a multifaceted process involving four steps: osteocyte activation, osteoclast-mediated bone resorption, surface preparation, and
osteoblast-mediated bone building. The bone remodeling process requires certain nutrients such as calcium, phosphorus,
magnesium, fluoride, vitamin D, and vitamin K.

[Link] [Link]
Discussion Starters
1. Analyze the shape of some of your bones. Recognize the varying structure of different bones that allows for the performance of
multiple functions. With a classmate, compare the shape of hand bones (that allow for fine articulated movements) to the shape
of foot bones and toe bones (that allow more awkward movement). If you designed a bone system to grasp a doorknob or hang
upside down, what would it look like? For inspiration, go to the web and look at bat bones, monkey bones, and human bones.
2. Why do you think it hurts when you hit your funny bone? Why are there no bones to protect the nerves?

9.2.1: Bone Structure and Function is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

[Link] [Link]
9.2.2: Bone Mineral Density is an Indicator of Bone Health
Learning Objectives
Identify the tests used to measure bone mass.

Bone mineral density (BMD) is a measurement of the amount of calcified tissue in grams per centimeter squared of bone tissue.
BMD can be thought of as the total amount of bone mass in a defined area. When BMD is high, bone strength will be great. Similar
to measuring blood pressure to predict the risk of stroke, a BMD measurement can help predict the risk of bone fracture. The most
common tool used to measure BMD is called dual energy X-ray absorptiometry (DEXA). During this procedure, a person lies on
their back and a DEXA scanner passes two X-ray beams through their body (Figure ). The amount of X-ray energy that
passes through the bone is measured for both beams. The total amount of the X-ray energy that passes through a person varies
depending on their bone thickness. Using this information and a defined area of bone, the amount of calcified tissue in grams per
unit area (cm2) is calculated.

Figure : Bone Densitometry Scan. This image was donated by Blausen

Medical. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762.
Most often the DEXA scan focuses on measuring BMD in the hip and the spine. These measurements are then used as indicators of
overall bone strength and health. DEXA is the cheapest and most accurate way to measure BMD. It also uses the lowest dose of
radiation. Other methods of measuring BMD include quantitative computed tomography (QCT) and radiographic absorptiometry.
People at risk for developing bone disease are advised to have a DEXA scan. We will discuss the many risk factors linked to an
increased incidence of osteoporosis and the steps a person can take to prevent the disease from developing.

[Link] [Link]
 DEXA - Dual Energy X-Ray Absorptiomet…
Absorptiomet…

Video : DEXA—Dual Energy X-Ray Absorptiometry (click to see

video).

Key Takeaways
Bone-mineral density is a measurement of calcified bone tissue and positively correlates with overall bone health. DEXA is a
clinical tool used to assess BMD.

Discussion Starter
1. Evaluate the animation below that discusses the technology of the DEXA procedure. Form a hypothesis on why doctors
recommend this procedure for women over age fifty. Discuss your findings.

9.2.2: Bone Mineral Density is an Indicator of Bone Health is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated
by LibreTexts.

[Link] [Link]
9.2.3: Micronutrients Essential for Bone Health- Calcium and Vitamin D
Learning Objectives
List the four primary functions of calcium in the human body.
Identify the Dietary Reference Intake for calcium.

Calcium
The most abundant mineral in the body is calcium, and greater than 99 percent of it is stored in bone tissue. Although only 1 percent of the calcium in the human body is found in the blood and soft
tissues, it is here that it performs the most critical functions. Blood calcium levels are rigorously controlled so that if blood levels drop the body will rapidly respond by stimulating bone resorption,
thereby releasing stored calcium into the blood. (This is discussed in further detail shortly.) Thus, bone tissue sacrifices its stored calcium to maintain blood calcium levels. This is why bone health is
dependent on the intake of dietary calcium and also why blood levels of calcium do not always correspond to dietary intake.

Figure : Calcium is an important mineral for multiple body functions. It is important to consume calcium-rich foods to
sustain proper dietary intake of calcium. (CC BY-SA 4.0;'Brookepinsent)

Calcium’s Functional Roles

Calcium plays a role in a number of different functions in the body:
Bone and tooth formation. The most well-known calcium function is to build and strengthen bones and teeth. Recall that when bone tissue first forms during the modeling or remodeling process,
it is unhardened, protein-rich osteoid tissue. In the osteoblast-directed process of bone mineralization, calcium phosphates (salts) are deposited on the protein matrix. The calcium salts gradually
crystallize into hydroxyapatite, which typically makes up about 65 percent of bone tissue. When your diet is calcium deficient, the mineral content of bone decreases causing it to become brittle
and weak. Thus, increased calcium intake helps to increase the mineralized content of bone tissue. Greater mineralized bone tissue corresponds to a greater BMD, and to greater bone strength. The
varying arrangements of the calcium-rich hydroxyapatite crystals on bone tissue’s protein matrix contribute to bone’s differing mechanical properties. In tooth enamel, hydroxyapatite crystals are
densely packed, making it the most mineralized tissue (more than 95 percent) in the human body. Tooth enamel’s densely packed crystal architecture provides it with its incredible strength and
durability. The mineralized bone tissue in human teeth is so incredibly strong that back molars can withstand bite forces exceeding four hundred pounds of pressure.
Nerve impulse transmission. Calcium facilitates electrical impulse transmission from one nerve cell to another. Calcium binds to vesicles that contain neurotransmitters, causing a release into the
neural synapses (junction between nerve cells). This allows the flow of ions in and out of nerve cells. If calcium is lacking, nerve-cell function will fail.
Muscle contraction. The flow of calcium ions along the muscle cell’s surface and the influx of calcium into the muscle cell are critical for muscle contraction. If calcium levels fall below a crucial
range, the muscles can’t relax after contracting. The muscles become stiff, and involuntary twitching may ensue in a condition known as tetany.
Clotting factors. When a blood vessel is injured and bleeding starts, it must be stopped or death may result. Clotting factors and platelets are continuously circulating in the blood in case of such
an emergency. When an injury occurs, the damaged tissue releases specific factors that activate the circulating clotting factors and platelets. Some of the clotting factors require calcium for
activation. If clotting factors weren’t activated blood clots would not form.
In addition to calcium’s four primary functions calcium has several other minor functions that are also critical for maintaining normal physiology. For example, without calcium, the hormone insulin
could not be released from cells in the pancreas and glycogen could not be broken down in muscle cells and used to provide energy for muscle contraction.

Maintaining Calcium Levels

Because calcium performs such vital functions in the body, blood calcium level is closely regulated by the hormones parathyroid hormone (PTH), calcitriol, and calcitonin. Calcitriol is the active
hormone produced from vitamin D. Parathyroid hormone and calcitriol act in a concert to increase calcium levels in the blood, while calcitonin does the opposite and decreases blood calcium levels.
These hormones maintain calcium levels in the blood in a range between 9 and 11 milligrams per deciliter.

Parathyroid Hormone
Four parathyroid glands, each the size of a grain of rice, can be found in the neck on the sides of the thyroid gland. PTH increases blood calcium levels via three different mechanisms (Figure ).
First, PTH stimulates the release of calcium stored in the bone. Second, PTH acts on kidney cells to increase calcium reabsorption and decrease its excretion in the urine. Third, PTH stimulates
enzymes in the kidney that activate vitamin D to calcitriol. Calcitriol acts on intestinal cells and increases dietary calcium absorption. Thus, stored calcium is released, more calcium is absorbed from
the diet, and less calcium is excreted, all of which increase calcium levels in the blood.

Figure : This is a typical negative feedback loop in which low calcium levels in the blood stimulate PTH release. PTH increases the movement
of calcium from the bones, kidneys, and intestine to the blood with the help of activated vitamin D. The now higher calcium levels in the blood shut off further PTH release. (CC-BY-SA 3.0; Mikael
Häggström).

[Link] [Link]
Calcitriol (1,25 Hydroxy-Vitamin D)
Calcitriol functions as a second hand to PTH. It not only increases calcium release from bone tissue, but also it increases the absorption of calcium in the small intestine and increases calcium
reabsorption by the kidneys. Neither hormone will work unless accompanied by the other. Vitamin D regulates PTH secretion and PTH regulates vitamin D activation to calcitriol. Adequate levels of
vitamin D allow for a balance of the calcium between what is released by bone tissue and what is incorporated into bone tissue, so that bone health is not compromised. Calcitriol and PTH function
together to maintain calcium homeostasis.

Calcitonin
Calcitonin is a hormone secreted by certain cells in the thyroid gland in response to high calcium levels in the blood. In comparison to PTH and calcitriol, calcitonin plays a small role in regulating
calcium levels on a day-to-day basis. This is because as calcium levels rise in the blood, calcium feedback inhibits PTH release and effectively shuts off the actions of PTH and calcitriol. This route of
feedback inhibition helps prevent calcium’s further accumulation in the blood. At higher nonphysiological concentrations, calcitonin lowers blood calcium levels by increasing calcium excretion in the
urine, preventing further absorption of calcium in the gut and by directly inhibiting bone resorption.

Other Health Benefits of Calcium in the Body

Besides forming and maintaining strong bones and teeth, calcium has been shown to have other health benefits for the body, including:
Cancer. The National Cancer Institute reports that there is enough scientific evidence to conclude that higher intakes of calcium decrease colon cancer risk and may suppress the growth of polyps
that often precipitate cancer. Although higher calcium consumption protects against colon cancer, some studies have looked at the relationship between calcium and prostate cancer and found
higher intakes may increase the risk for prostate cancer; however the data is inconsistent and more studies are needed to confirm any negative association.
Blood pressure. Multiple studies provide clear evidence that higher calcium consumption reduces blood pressure. A review of twenty-three observational studies concluded that for every 100
milligrams of calcium consumed daily, systolic blood pressure is reduced 0.34 millimeters of mercury (mmHg) and diastolic blood pressure is decreased by 0.15 [Link], N. J. “Comments
on a Meta-Analysis of the Relation between Dietary Calcium Intake and Blood Pressure.” Am J Epidemiol 148, no. 3 (1998): 223–28. [Link] There is
emerging evidence that higher calcium intakes prevent against other risk factors for cardiovascular disease, such as high cholesterol and obesity, but the scientific evidence is weak or inconclusive.
Kidney stones. Another health benefit of a high-calcium diet is that it blocks kidney stone formation. Calcium inhibits the absorption of oxalate, a chemical in plants such as parsley and spinach,
which is associated with an increased risk for developing kidney stones. Calcium’s protective effects on kidney stone formation occur only when you obtain calcium from dietary sources. Calcium
supplements may actually increase the risk for kidney stones in susceptible people.

Calcium Needs, Sources, and Bioavailability

Dietary Reference Intake for Calcium

The recommended dietary allowances (RDA) for calcium are listed in Table . The RDA is elevated to 1,300 milligrams per day during adolescence because this is the life stage with accelerated
bone growth. Studies have shown that a higher intake of calcium during puberty increases the total amount of bone tissue that accumulates in a person. For women above age fifty and men older than
seventy-one, the RDAs are also a bit higher for several reasons including that as we age, calcium absorption in the gut decreases, vitamin D3 activation is reduced, and maintaining adequate blood
levels of calcium is important to prevent an acceleration of bone tissue loss (especially during menopause). Currently, the dietary intake of calcium for females above age nine is, on average, below
the RDA for calcium. The Institute of Medicine (IOM) recommends that people do not consume over 2,500 milligrams per day of calcium as it may cause adverse effects in some people.
Table : Dietary Reference Intakes for Calcium

Age Group RDA (mg/day) UL (mg/day)

Infants (0–6 months) 200* –

Infants (6–12 months) 260* –

Children (1–3 years) 700 2,500

Children (4–8 years) 1,000 2,500

Children (9–13 years) 1,300 2,500

Adolescents (14–18 years) 1,300 2,500

Adults (19–50 years) 1,000 2,500

Adult females (50–71 years) 1,200 2,500

Adults, male & female (> 71 years) 1,200 2,500

* denotes Adequate Intake. Source: Ross, A. C. et al. “The 2011 Report on Dietary Reference Intakes for Calcium and Vitamin D from the Institute of Medicine: What Clinicians Need to Know.” J Clin
Endocrinol Metab 96, no. 1 (2011): 53–8. US National Library of Medicine. [Link]

Figure : Incorporate tofu, an excellent source of calcium, into your diet. Tofu kabobs make a delicious meal. © Shutterstock
In the typical American diet, calcium is obtained mostly from dairy products, primarily cheese. A slice of cheddar or Swiss cheese contains just over 200 milligrams of calcium. One cup of nonfat
milk contains approximately 300 milligrams of calcium, which is about a third of the RDA for calcium for most adults. Foods fortified with calcium such as cereals, soy milk, and orange juice also
provide one third or greater of the calcium RDA. Although the typical American diet relies mostly on dairy products for obtaining calcium, there are many other good nondairy sources of calcium
(Table ). A food’s calcium content can be calculated from the percent daily value (percent DV) displayed on the Nutrition Facts panel (Figure ). Since the RDA for calcium used to
calculate the daily value (DV) is 1,000 milligrams, you multiply the percent DV by ten to arrive at the calcium content in milligrams for a serving of a particular food. It is important to note that most
processed foods offer a poor source for this vital mineral as the refinement process strips away the nutrients in the food.

Tools for Change

If you need to increase calcium intake, are a vegan, or have a food allergy to dairy products, it is helpful to know that there are several plant-based foods that are high in calcium. Broccoli, kale,
mustard greens, and Brussel sprouts are excellent sources. One cup of these cooked vegetables provides between 100 and 180 milligrams of calcium. To increase the calcium content in your lunch and

[Link] [Link]
add some texture to your food, chop up some kale and put it on your sandwich or in your soup. For a list of nondairy sources that are high in calcium, see Table . Additionally, you can find the
calcium content for thousands of foods by visiting the USDA National Nutrient Database ([Link]/fnic/foodcomp/search/). When obtaining your calcium from a vegan diet, it is important
to know that some plant-based foods significantly impair the absorption of calcium. These include spinach, Swiss chard, rhubarb, beets, cashews, and peanuts. With careful planning and good
selections, you can ensure that you are getting enough calcium in your diet even if you do not drink milk or consume other dairy products.

Figure : How to Calculate Calcium in Milligrams from the Nutrition Facts Panel
The percent DV of calcium is given on the Nutrition Facts panel. To convert this to milligrams (mg), multiply this number by ten. This is the amount of calcium in milligrams in one serving. This can
be done this easily ONLY for calcium and not for other nutrients because the DV for calcium, based on the RDA for adults between the ages of nineteen and fifty, is equal to 1,000 milligrams.
Table : Nondairy Dietary Sources of Calcium

Food, Standard Amount Calcium (mg) Calories

Fortified ready-to-eat cereals (various), 1 oz. 236–1043 88–106

Soy beverage, calcium fortified, 1 c. 368 98

Sardines, Atlantic, in oil, drained, 3 oz. 325 177

Tofu, firm, prepared with nigarib, ½ c. 253 88

Pink salmon, canned, with bone, 3 oz. 181 118

Collards, cooked from frozen, ½ c. 178 31

Molasses, blackstrap, 1 Tbsp. 172 47

Soybeans, green, cooked, ½ c. 130 127

Turnip greens, cooked from frozen, ½ c. 124 24

Ocean perch, Atlantic, cooked, 3 oz. 116 103

Oatmeal, plain and flavored, instant, fortified, 1 packet prepared 99–110 97–157

Cowpeas, cooked, ½ c. 106 80

White beans, canned, ½ c. 96 153

Kale, cooked from frozen, ½ c. 90 20

Okra, cooked from frozen, ½ c. 88 26

Soybeans, mature, cooked, ½ c. 88 149

Blue crab, canned, 3 oz. 86 84

Beet greens, cooked from fresh, ½ c. 82 19

Pak-choi, Chinese cabbage, cooked from fresh, ½ c. 79 10

Clams, canned, 3 oz. 78 126

Dandelion greens, cooked from fresh, ½ c. 74 17

Rainbow trout, farmed, cooked, 3 oz. 73 144

Source: US Department of Agriculture. Appendix B-4, “Nondairy Food Sources of Calcium.” 2005 Dietary Guidelines for Americans. Updated July 9, 2008.
[Link]/dietaryguidelines/dga2005/document/html/[Link].

Calcium Bioavailability
Bioavailability refers to the amount of a particular nutrient in foods that is actually absorbed in the intestine and not eliminated in the urine or feces. Simply put, the bioavailability of calcium is the
amount that is on hand to perform its biological functions. In the small intestine, calcium absorption primarily takes place in the duodenum (first section of the small intestine) when intakes are low,
but calcium is also absorbed passively in the jejunum and ileum (second and third sections of the small intestine), especially when intakes are higher. The body doesn’t completely absorb all the
calcium in food. About 30 percent of calcium is absorbed from milk and other dairy products. Interestingly, the calcium in some vegetables such as kale, Brussel sprouts, and bok choy, is better
absorbed by the body than are dairy products. The body absorbs approximately 50 percent of calcium from these plant-based sources.

Factors that Increase Calcium Bioavailability

Stomach acid releases calcium from foods and ionizes it to Ca++. Calcium must be in its ionized form to be absorbed in the small intestine. The greatest positive influence on calcium absorption
comes from having an adequate intake of vitamin D. People deficient in vitamin D absorb less than 15 percent of calcium from the foods they eat. The hormone estrogen is another factor that

[Link] [Link]
enhances calcium bioavailability. Thus, as a woman ages and goes through menopause, during which estrogen levels fall, the amount of calcium absorbed decreases and the risk for bone disease
increases. Some fibers, such as inulin, found in jicama, onions, and garlic, also promote calcium intestinal uptake.

Factors that Decrease Calcium Bioavailability

Chemicals that bind to calcium decrease its bioavailability. These negative effectors of calcium absorption include the oxalates in certain plants, the tannins in tea, phytates in nuts, seeds, and grains,
and some fibers. Oxalates are found in high concentrations in spinach, parsley, cocoa, and beets. In general, the calcium bioavailability is inversely correlated to the oxalate content in foods. High-
fiber, low-fat diets also decrease the amount of calcium absorbed, an effect likely related to how fiber and fat influence the amount of time food stays in the gut. Anything that causes diarrhea,
including sicknesses, medications, and certain symptoms related to old age, decreases the transit time of calcium in the gut and therefore decreases calcium absorption. As we get older, stomach
acidity sometimes decreases, diarrhea occurs more often, kidney function is impaired, and vitamin D absorption and activation is compromised, all of which contribute to a decrease in calcium
bioavailability.

Vitamin D
Vitamin D refers to a group of fat-soluble vitamins derived from cholesterol. Vitamins D2 and D3 are the only ones known to have biological actions in the human body. Although vitamin D3 is called
a vitamin, the body can actually synthesize vitamin D3. When exposed to sunlight, a cholesterol precursor in the skin is transformed into vitamin D3. However, this is not the bioactive form of vitamin
D. It first must be acted upon by enzymes in the liver and then transported to the kidney where vitamin D3 is finally transformed into the active hormone, calcitriol (1,25-dihydroxy vitamin D3)
(Figure ).

Figure : Vitamin D Food Sources. © Networkgraphics

The skin synthesizes vitamin D when exposed to sunlight. In fact, for most people, more than 90 percent of their vitamin D3 comes from the casual exposure to the UVB rays in sunlight. Anything
that reduces your exposure to the sun’s UVB rays decreases the amount of vitamin D3 your skin synthesizes. That would include long winters, your home’s altitude, whether you are wearing
sunscreen, and the color of your skin (including tanned skin). Do you ever wonder about an increased risk for skin cancer by spending too much time in the sun? Do not fret. Less than thirty minutes
of sun exposure to the arms and legs will increase blood levels of vitamin D3 more than orally taking 10,000 IU (250 micrograms) of vitamin D3. However, it important to remember that the skin
production of vitamin D3 is a regulated process, so too much sun does cause vitamin D toxicity.

Interactive : Vitamin D Production in the Body

Visit the University of North Carolina Gillings School of Global Public Health website to review the activation of vitamin D to calcitriol. [Link]/tlim/nutr240/?6

A person’s vitamin D status is determined by measuring 25-hydroxy vitamin D3 levels in the blood serum because it reflects both the vitamin D obtained from production in the skin and that from
dietary sources. Measuring the active hormone, calcitriol, does not accurately reflect one’s vitamin D status because of its short half-life (six to twelve hours). The vast majority of nutrition experts
consider a concentration of 25-hydroxy vitamin D3 in the blood serum less than 20 nanograms per millileter as an indicator of vitamin D deficiency. The IOM states that serum levels above 20
nanograms per milliliter are sufficient to maintain bone health in healthy individuals. Both nutrition experts and health advocates currently are debating what the optimal levels of vitamin D3 should
be to take full advantage of all of its health benefits. Some advocates propose that serum levels of vitamin D3 above 40 nonograms per milliliter are optimal. To determine whether higher levels of
vitamin D3 provide advantages in fighting diseases such as cancer, a large clinical trial called VITAL (Vitamin D and Omega-3 Trial) has been initiated at Brigham and Women’s Hospital and Harvard
Medical School in Boston, Massachusetts. To remain updated on this trial, visit their website at [Link]

Figure : The Activation of Vitamin D to Calcitriol. © Networkgraphics

Vitamin D’s Functional Role

As previously discussed, activated vitamin D3 (calcitriol) regulates blood calcium levels in concert with parathyroid hormone. In the absence of an adequate intake of vitamin D, less than 15 percent
of calcium is absorbed from foods or supplements. The effects of calcitriol on calcium homeostasis are critical for bone health. A deficiency of vitamin D in children causes the bone disease
nutritional rickets. Rickets is very common among children in developing countries and is characterized by soft, weak, deformed bones that are exceptionally susceptible to fracture. In adults, vitamin

[Link] [Link]
D deficiency causes a similar disease called osteomalacia, which is characterized by low BMD. Osteomalacia has the same symptoms and consequences as osteoporosis and often coexists with
osteoporosis. Vitamin D deficiency is common, especially in the elderly population, dark-skinned populations, and in the many people who live in the northern latitudes where sunlight exposure is
much decreased during the long winter season.
Observational studies have shown that people with low levels of vitamin D in their blood have lower BMD and an increased incidence of osteoporosis. In contrast, diets with high intakes of salmon,
which contains a large amount of vitamin D, are linked with better bone health. A review of twelve clinical trials, published in the May 2005 issue of the Journal of the American Medical Association,
concluded that oral vitamin D supplements at doses of 700–800 international units per day, with or without coadministration of calcium supplements, reduced the incidence of hip fracture by 26
percent and other nonvertebral fractures by 23 percent.“Fracture Prevention with Vitamin D Supplementation: A Meta-Analysis of Randomized Controlled Trials.” JAMA 293, no. 18 (2005): 2257–64.
[Link]/content/293/18/[Link]. A reduction in fracture risk was not observed when people took vitamin D supplements at doses of 400 international units.

Vitamin D Needs and Sources

Dietary Reference Intake for Vitamin D

The Institute of Medicine RDAs for vitamin D for different age groups is listed in Table . For adults, the RDA is 600 international units, which is equivalent to 15 micrograms of vitamin D. The
National Osteoporosis Foundation recommends slightly higher levels and that adults under age fifty get between 400 and 800 international units of vitamin D every day, and adults fifty and older get
between 800 and 1,000 international units of vitamin D every day. According to the IOM, the tolerable upper intake level (UL) for vitamin D is 4,000 international units per day. Toxicity from excess
vitamin D is rare, but certain diseases such as hyperparathyroidism, lymphoma, and tuberculosis make people more sensitive to the increases in calcium caused by high intakes of vitamin D.
Table : Dietary Reference Intakes for Vitamin D
Age Group RDA (mcg/day) UL (mcg/day)

Infant (0–6 months) 10* 25

Infants (6–12 months) 10* 25

Children (1–3 years) 15 50

Children (4–8 years) 15 50

Children (9–13 years) 15 50

Adolescents (14–18 years) 15 50

Adults (19–71 years) 15 50

Adults (> 71 years) 20 50

* denotes Adequate Intake

Source: Ross, A. C. et al. “The 2011 Report on Dietary Reference Intakes for Calcium and Vitamin D from the Institute of Medicine: What Clinicians Need to Know.” J Clin Endocrinol Metab 96, no.
1 (2011): 53–8. [Link]

Vitamin D Bioavailability
There are few food sources of vitamin D. Oily fish, such as salmon, is one of the best. The amount of vitamin D obtained from one 3-ounce piece of salmon is greater than the recommended intake for
one day. Many foods, including dairy products, orange juice, and cereals are now fortified with vitamin D. Most vitamin-D-fortified foods contain about 25 percent of the RDA for vitamin D per
serving, but check the label. Many people are deficient in vitamin D as a result of the few dietary sources for this vitamin.

Other Health Benefits of Vitamin D in the Body

Many other health benefits have been linked to higher intakes of vitamin D, from decreased cardiovascular disease to the prevention of infection. Furthermore, evidence from laboratory studies
conducted in cells, tissues, and animals suggest vitamin D prevents the growth of certain cancers, blocks inflammatory pathways, reverses atherosclerosis, increases insulin secretion, and blocks viral
and bacterial infection and many other things. Vitamin D deficiency has been linked to an increased risk for autoimmune diseases. (Autoimmune diseases are those that result from an abnormal
immune response targeted against the body’s own tissues.) An increased prevalence of the autoimmune diseases, rheumatoid arthritis, multiple sclerosis, and Type 1 diabetes has been observed in
populations with inadequate vitamin D levels. Additionally, vitamin D deficiency is linked to an increased incidence of hypertension. Until the results come out from the VITAL study, the bulk of
scientific evidence touting other health benefits of vitamin D is from laboratory and observational studies and requires confirmation in clinical intervention studies.

Key Takeaways
Calcium is the most abundant mineral in the body and has four primary functions: making bones strong and healthy, facilitating nerve-to-nerve communication, stimulating muscle contraction, and
activating blood-clotting factors. Other benefits of calcium in the body include decreasing blood pressure and preventing colon cancer. Calcium blood-levels are rigorously controlled by three
hormones: PTH, calcitriol, and calcitonin. The DRI for calcium intake for adults averages from 1,000–1,200 milligrams per day. Only some of the calcium in food is absorbed by the body. Vitamin D
and estrogen enhance the bioavailability of calcium in the body. Alternately, diets high in oxalates, some types of fiber, and diets low in fat decrease the bioavailability of calcium in the body. Vitamin
D is essential for maintaining calcium levels in the body. Once activated to calcitriol, it acts in concert with PTH to keep blood levels of calcium constant, especially by enhancing its intestinal
absorption. High levels of vitamin D in the blood promote bone health.

Discussion Starters
1. Talk about some of the vital functions of calcium and vitamin D in the body. Why are these nutrients so important to health? What can you do to increase these vitamins in your diet?
2. Watch the video below. List the pros and cons of consuming both raw and pasteurized milk. Develop an informed opinion based upon the history of milk and the scientific evidence about both
types of milk consumption.

[Link] [Link]
 Raw Milk

Video : Raw milk is a risk not worth taking. The benefits just don't outweigh the costs. If it had some measurable health benefit that we couldn't obtain some other way, that would change my
perspective. As it stands though, the only benefit is flavor and the liberty to do it. The cost is the risk of disease or death. I can't find a way to make those two balance out.

9.2.3: Micronutrients Essential for Bone Health- Calcium and Vitamin D is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

[Link] [Link]
9.2.4: Osteoporosis
Learning Objectives
Describe osteoporosis, including its notable characteristics

There are several factors that lead to loss of bone quality during aging, including a reduction in hormone levels, decreased calcium
absorption, and increased muscle deterioration. It is comparable to being charged with the task of maintaining and repairing the
structure of your home without having all of the necessary materials to do so. However, you will learn that there are many ways to
maximize your bone health at any age.
Osteoporosis is the excessive loss of bone over time. It leads to decreased bone strength and an increased susceptibility to bone
fracture. The Office of the Surgeon General (OSG) reports that approximately ten million Americans over age fifty are living with
osteoporosis, and an additional thirty-four million have osteopenia, which is lower-than-normal bone mineral [Link] of the
Surgeon General. “Bone Health and Osteoporosis: A Report of the Surgeon General.” October 2004.
[Link]/librar...chapter_1.html. Osteoporosis is a debilitating disease that markedly increases the risks of
suffering from bone fractures. A fracture in the hip causes the most serious consequences—and approximately 20 percent of senior
citizens who have one will die in the year after the injury. Osteoporosis affects more women than men, but men are also at risk for
developing osteoporosis, especially after the age of seventy. These statistics may appear grim, but many organizations—including
the National Osteoporosis Foundation and the OSG—are disseminating information to the public and to health-care professionals
on ways to prevent the disease, while at the same time, science is advancing in the prevention and treatment of this
[Link] Osteoporosis Foundation. “Facts and Statistics about Osteoporosis and Its Impact.” © 2012 International
Osteoporosis Foundation. Accessed [Link]
As previously discussed, bones grow and mineralize predominately during infancy, childhood, and puberty. During this time, bone
growth exceeds bone loss. By age twenty, bone growth is fairly complete and only a small amount (about 10 percent) of bone mass
accumulates in the third decade of life. By age thirty, bone mass is at its greatest in both men and women and then gradually
declines after age forty. Bone mass refers to the total weight of bone tissue in the human body. The greatest quantity of bone tissue
a person develops during his or her lifetime is called peak bone mass. The decline in bone mass after age forty occurs because bone
loss is greater than bone growth. On a cellular level, this means that the osteoclast-mediated bone degradation exceeds that of the
bone building activity of osteoblasts. The increased bone degradation decreases the mineral content of bone tissue leading to a
decrease in bone strength and increased fracture risk.
Osteoporosis is referred to as a silent disease, much like high blood pressure, because symptoms are rarely exhibited. A person with
osteoporosis may not know he has the disease until he experiences a bone break or fracture. Detection and treatment of
osteoporosis, before the occurrence of a fracture, can significantly improve the quality of life. To detect osteopenia or osteoporosis,
BMD must be measured by the DEXA procedure. The results of a BMD scan are most often reported as T-scores. A T-score
compares a person’s BMD to an averaged BMD of a healthy thirty-year-old population of the same sex. According to the World
Health Organization, a T-score of −1.0 or above indicates normal BMD. A person with a T-score between −1.0 and −2.5 has a low
BMD, which is a condition referred to as osteopenia. A person with a T-score of −2.5 or below is diagnosed with osteoporosis.
National Osteoporosis Foundation. “Having A Bone Density Test.” © 2011. [Link]/node/42 This classification of T-scores is
based on studies of white postmenopausal women and does not apply to premenopausal women, nonwhite postmenopausal women,
or men.
Osteoporosis is categorized into two types that differ by the age of onset and what type of bone tissue is most severely deteriorated.
Type 1 osteoporosis, also called postmenopausal osteoporosis, most often develops in women between the ages of fifty and
seventy. Between the ages of forty-five and fifty, women go through menopause and their ovaries stop producing estrogen. Because
estrogen plays a role in maintaining bone mass, its rapid decline during menopause accelerates bone loss. This occurs mainly as a
result of increased osteoclast activity. The trabecular tissue is more severely affected because it contains more osteoclasts cells than
cortical tissue. Type 1 osteoporosis is commonly characterized by wrist and spine fractures. Type 2 osteoporosis is also called
senile osteoporosis and typically occurs after the age of seventy. It affects women twice as much as men and is most often
associated with hip and spine fractures. In Type 2 osteoporosis, both the trabecular and cortical bone tissues are significantly

[Link] [Link]
affected. Not everybody develops osteoporosis as they age. Other factors also contribute to the risk or likelihood of developing the
disease.

Figure : Osteoporosis in Vertebrae. Osteoporosis is characterized by a

gradual weakening of the bones, which leads to poor skeletal formation. (CC BY-SA 3.0; [Link] staff (2014). WikiJournal of
Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.
During the course of both types of osteoporosis, BMD decreases and the bone tissue microarchitecture is compromised. Excessive
bone resorption in the trabecular tissue increases the size of the holes in the lattice-like structure making it more porous and weaker.
A disproportionate amount of resorption of the strong cortical bone causes it to become thinner. The deterioration of one or both
types of bone tissue causes bones to weaken and, consequently, become more susceptible to fractures. The American Academy of
Orthopaedic Surgeons reports that one in two women and one in five men older than sixty-five will experience a bone fracture
caused by [Link] Academy of Orthopaedic Surgeons. “Osteoporosis.” © 1995–2012. Last reviewed August 2009.
[Link]/[Link]?topic=a00232.
When the vertebral bone tissue is weakened, it can cause the spine to curve (Figure ). The increase in spine curvature not
only causes pain, but also decreases a person’s height. Curvature of the upper spine produces what is called Dowager’s hump, also
known as kyphosis. Severe upper-spine deformity can compress the chest cavity and cause difficulty breathing. It may also cause
abdominal pain and loss of appetite because of the increased pressure on the abdomen.

[Link] [Link]
 Osteoporosis-3D Medical Animation

Video : Osteoporosis Defined. See this 3D medical animation about

osteoporosis (click to see video).

Key Takeaways
Bone mineral density (BMD) is an indicator of bone quality and correlates with bone strength. Excessive bone loss can lead to the
development of osteopenia and eventually osteoporosis. Osteoporosis affects women more than men, but is a debilitating disease
for either sex. Osteoporosis is often a silent disease that doesn’t manifest itself until a fracture is sustained.

Discussion Starters
1. Discuss how bone microarchitecture is changed in people with osteoporosis. How do these structural changes increase the risk
of having a bone fracture?

9.2.4: Osteoporosis is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

[Link] [Link]
[Link]: Risk Factors for Osteoporosis
Learning Objectives

Discuss risk factors for osteoporosis.

A risk factor is defined as a variable that is linked to an increased probability of developing a disease or adverse outcome. Recall
that advanced age and being female increase the likelihood for developing osteoporosis. These factors present risks that should
signal doctors and individuals to focus more attention on bone health, especially when the risk factors exist in combination. This is
because not all risk factors for osteoporosis are out of your control. Risk factors such as age, gender, and race are biological risk
factors, and are based on genetics that cannot be changed. By contrast, there are other risk factors that can be modified, such as
physical activity, alcohol intake, and diet. The changeable risk factors for osteoporosis provide a mechanism to improve bone
health even though some people may be genetically predisposed to the disease.

Figure : Certain risk factors for developing osteoporosis are biological, such as being Caucasian or Asian and being over
age forty. Other factors are related to lifestyle choices such as smoking. © Shutterstock

Nonmodifiable Risk Factors

Age, Sex, Body Type, and Heredity
As noted previously, after age forty, bone mass declines due to bone breakdown exceeding bone building. Therefore, any person
over the age of forty has an increased probability of developing osteoporosis in comparison to a younger person. As noted, starting
out with more bone (a high peak bone mass) enables you to lose more bone during the aging process and not develop osteoporosis.
Females, on average, have a lower peak bone mass in comparison to males and therefore can sustain less bone tissue loss than
males before developing a low BMD. Similarly, people with small frames are also at higher risk for osteoporosis. Being of
advanced age, being a woman, and having a small frame are all biological risk factors for osteoporosis. Other biological risk factors
that are linked to an increased likelihood of developing osteoporosis are having low estrogen levels, or another endocrine disorder
such as hyperthyroidism, having a family member with osteoporosis, and being Caucasian or Asian.

Estrogen Level
Estrogen is the primary female reproductive hormone and it stimulates osteoblast-mediated bone building and reduces osteoclast
activity. Any condition in which estrogen levels are reduced throughout a woman’s life decreases BMD and increases the risk for
osteoporosis. By far the most profound effect on estrogen occurs during female menopause. Around the age of forty-five or fifty,

[Link].1 [Link]
women stop producing estrogen. The rapid decline in estrogen levels that occurs during menopause speeds up the bone resorptive
process, and as a result the loss of bone tissue in menopausal women lasts for a period of five to ten years. Up to 3 percent of bone
tissue is lost annually during menopause and therefore potentially 30 percent of peak bone mass can vanish during this time,
leading to a substantial increase in risk for developing osteoporosis in postmenopausal women.

Medications
Some medications, most notably glucocorticoids (used to treat inflammatory disorders such as rheumatoid arthritis and asthma), are
associated with an increased risk for osteoporosis. A side effect of glucocorticoids is that they stimulate bone resorption and
decrease bone building. Other medications linked to an increased risk for osteoporosis are certain anticancer drugs, some
antidiabetic drugs, and blood thinners.

Other Diseases
Diseases that predispose people to osteoporosis include those that disrupt nutrient absorption and retention, such as anorexia
nervosa, chronic kidney disease, and Crohn’s disease; diseases that influence bone remodeling such as hyperthyroidism and
diabetes; and diseases that are characterized by chronic inflammatory responses such as cancer, chronic obstructive pulmonary
disease, and rheumatoid arthritis.

Modifiable Risk Factors

Physical Inactivity
Bone is a living tissue, like muscle, that reacts to exercise by gaining strength. Physical inactivity lowers peak bone mass, decreases
BMD at all ages, and is linked to an increase in fracture risk, especially in the elderly. Recall that mechanical stress increases bone
remodeling and leads to increased bone strength and quality. Weight-bearing exercise puts mechanical stress on bones and therefore
increases bone quality. The stimulation of new bone growth occurs when a person participates in weight-bearing or resistance
activities that force the body to work against gravity. Research has shown that this is an excellent way to activate osteoblasts to
build more new bone. Conversely, physical inactivity lowers peak bone mass, decreases BMD at all ages, and is linked to an
increase in fracture risk, especially in the elderly.

Figure : Dancing is a form of weight-bearing

activity that forces the body to move against gravity and therefore stimulates new bone growth. San Francisco Sunday Streets:
Valencia. (CC-BY-2.0; David McSpadden).

Being Underweight
Being underweight significantly increases the risk for developing osteoporosis. This is because people who are underweight often
also have a smaller frame size and therefore have a lower peak bone mass. Maintaining a normal, healthy weight is important and
acts as a form of weight-bearing exercise for the skeletal system as a person moves about. Additionally, inadequate nutrition
negatively impacts peak bone mass and BMD. The most striking relationship between being underweight and bone health is seen in
people with the psychiatric illness anorexia nervosa. Anorexia nervosa is strongly correlated with low peak bone mass and a low
BMD. In fact, more than 50 percent of men and women who have this illness develop osteoporosis and sometimes it occurs very
early in [Link], P. S. and K. Weiner. “The Risk of Osteoporosis in Anorexia Nervosa.” Reprinted from Eating Disorders

[Link].2 [Link]
Recovery Today 1, no. 5 (Summer 2003). © 2003 Gurze Books. [Link]...edt_1_5_2.html Women with
anorexia nervosa are especially at risk because they not only have inadequate nutrition and low body weight, but also the illness is
also associated with estrogen deficiency.

Smoking, Alcohol, and Caffeine

Smoking cigarettes has long been connected to a decrease in BMD and an increased risk for osteoporosis and fractures. However,
because people who smoke are more likely to be physically inactive and have poor diets, it is difficult to determine whether
smoking itself causes osteoporosis. What is more, smoking is linked to earlier menopause and therefore the increased risk for
developing osteoporosis among female smokers may also be attributed, at least in part, to having stopped estrogen production at an
earlier age. A review of several studies, published in the British Medical Journal in 1997, reports that in postmenopausal women
who smoked, BMD was decreased an additional 2 percent for every ten-year increase in age and that these women had a substantial
increase in the incidence of hip [Link], M. R. and A.K. Hackshaw. “A Meta-Analysis of Cigarette Smoking, Bone Mineral
Density and Risk of Hip Fracture: Recognition of a Major Effect.” Br Med J 315, no. 7112 (October 4, 1997): 841–6.
[Link]
Alcohol intake’s effect on bone health is less clear. In some studies, excessive alcohol consumption was found to be a risk factor for
developing osteoporosis, but the results of other studies suggests consuming two drinks per day is actually associated with an
increase in BMD and a decreased risk for developing osteoporosis. The International Osteoporosis Foundation states that
consuming more than two alcoholic drinks per day is a risk factor for developing osteoporosis and sustaining a hip fracture in both
men and [Link] Osteoporosis Foundation. “New IOF Report Shows Smoking, Alcohol, Being Underweight, and
Poor Nutrition Harm our Bones.” Accessed October 2011. [Link] Moreover,
excessive alcohol intake during adolescence and young adulthood has a more profound effect on BMD and osteoporosis risk than
drinking too much alcohol later in life.
Some studies have found that, similar to alcohol intake, excessive caffeine consumption has been correlated to decreased BMD, but
in other studies moderate caffeine consumption actually improves BMD. Overall, the evidence that caffeine consumption poses a
risk for developing osteoporosis is scant, especially when calcium intake is sufficient. Some evidence suggests that carbonated soft
drinks negatively affect BMD and increase fracture risk. Their effects, if any, on bone health are not attributed to caffeine content
or carbonation. It is probable that any effects of the excessive consumption of soft drinks, caffeinated or not, on bone health can be
attributed to the displacement of milk as a dietary source of calcium.

Nutrition
Ensuring adequate nutrition is a key component in maintaining bone health. Having low dietary intakes of calcium and vitamin D
are strong risk factors for developing osteoporosis. Another key nutrient for bone health is protein. Remember that the protein
collagen comprises almost one third of bone tissue. A diet inadequate in protein is a risk factor for osteoporosis. Multiple large
observational studies have shown that diets high in protein increase BMD and reduce fracture risk and that diets low in protein
correlate to decreased BMD and increased fracture risk. There has been some debate over whether diets super high in animal
protein decrease bone quality by stimulating bone resorption and increasing calcium excretion in the urine. A review in the May
2008 issue of the American Journal of Clinical Nutrition concludes that there is more evidence that diets adequate in protein play a
role in maximizing bone health and there is little consistent evidence that suggests high protein diets negatively affect bone health
when calcium intake is [Link], R. P. and D.K. Layman. “Amount and Type of Protein Influences Bone Health.” Am J
Clin Nutr 87, no. 5 (2008): 1567S–70S. [Link]

Key Takeaways
Nonmodifiable risk factors for osteoporosis include: being female, being over age fifty, having a small frame, having an endocrine
disorder, having a family member with the disease, and being Caucasian or Asian. The risk factors for osteoporosis that can be
changed are: smoking, alcohol intake, physical inactivity, and poor nutrition. Dietary inadequacy, certain medications, and diseases
increase the risk for developing osteoporosis.

[Link].3 [Link]
Discussion Starter
1. Discuss why it is important for a person with more than one biological risk factor for osteoporosis to begin to manage their
lifestyle early on to prevent the development of the disease.

[Link]: Risk Factors for Osteoporosis is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

[Link].4 [Link]
[Link]: Osteoporosis Prevention and Treatment
Learning Objectives
Explain why it is important to build peak bone mass when you are young.
Identify the tests used to measure bone mass.

Although the symptoms of osteoporosis do not occur until old age, osteoporosis is referred to as a childhood disease with old-age
consequences. Thus, preventing osteoporosis in old age begins with building strong bones when you are growing. Remember, the
more bone mass a person has to start with, the greater the loss a person can withstand without developing osteopenia or
osteoporosis. Growing and maintaining healthy bones requires good nutrition, adequate intake of minerals and vitamins that are
involved in maintaining bone health, and weight-bearing exercise.

Figure : An exercise group engages in weight-bearing activity, which

is a primary way to prevent osteoporosis. © Shutterstock

Primary Prevention
Actions taken to avoid developing a disease before it starts are considered primary prevention. Primary prevention of osteoporosis
begins early on in life. About one half of mineralized bone is built during puberty and the requirements for calcium intake are
higher at this time than at other times in life. Unfortunately, calcium intake in boys and girls during adolescence is usually below
the recommended intake of 1,300 milligrams per day. To combat inadequate nutrition and physical inactivity in adolescents, the US
Department of Health and Human Services launched the Best Bones Forever!™ campaign in [Link] Department of Health and
Human Services. Best Bones Forever! Last updated September 2009. [Link]/[Link] This campaign is
focused on promoting bone health, especially in girls, and reducing the incidence of osteoporosis in women.

Interactive
Visit the Best Bones Forever!™ website. [Link]/[Link]

An article in the October 2008 issue of Food and Nutrition Research concluded that there is extensive evidence that when girls and
boys exercise they increase their peak bone mass and build a stronger skeleton. The greatest benefits to bone health were observed
when exercise was combined with good [Link], M. K., A. Nordqvist, and C. Karlsson. “Physical Activity Increases
Bone Mass during Growth.” Food and Nutrition Research 52 (Published online October 1, 2008). doi: 10.3402/fnr.v52i0.1871
Because there is such a strong correlation between peak bone mass and a decreased risk for developing osteoporosis, a main thrust
of organizations that promote bone health, such as the National Osteoporosis Foundation, is to provide information on how to
increase skeletal health early on in life, particularly during the time period of peak bone growth, which is puberty.
Primary prevention extends throughout life, and people with one or more risk factors for osteoporosis should have their BMD
measured. The National Osteoporosis Foundation recommends the following groups of people get BMD screening:
Women who are sixty-five or older
Men who are seventy or older
Women and men who break a bone after age fifty
Women going through menopause with other risk factors

[Link].1 [Link]
 Men fifty to sixty-nine years of age with risk factorsNational Osteoporosis Foundation. “National Osteoporosis Foundation on
Bone Mineral Density Testing.” [Link]/node/501

Primary Prevention Tactics

Nutrition: Eat Right for Your Bones

Eating a balanced diet throughout life is helpful in preventing the onset of osteoporosis and deleterious fractures in old age. There
is ample scientific evidence to suggest that low intakes of calcium and vitamin D in adulthood are linked to an increased risk for
developing osteoporosis. Therefore, it is essential to make sure your diet contains adequate levels of these nutrients. The roles of
calcium and vitamin D in maintaining bone health are discussed in detail elsewhere of this chapter.

Physical Activity: Use It or Lose It

Mechanical stress is one of the activation signals for bone remodeling and can increase bone strength. Exercises that apply forces to
the bone increase BMD. The most helpful are weight-bearing exercises such as strength training with weights, and aerobic weight-
bearing activities, such as walking, running, and stair climbing. Certain aerobic exercises such as biking and swimming do not
build bones, although they are very good for cardiovascular fitness. The importance of weight-bearing exercise to bone health is
seen most clearly in astronauts. Investigators who analyzed the BMD of astronauts found that typically it decreases by 1.8 percent
every month in space. That means during a six-month stay at a space station an astronaut may lose greater than 10 percent of their
bone mass. The lack of gravity, which tugs on the bones of people on Earth every day, is what causes bone mass loss in astronauts.
NASA imposes a rigorous workout to prevent and to restore the loss of bone mass in astronauts. While in space, astronauts exercise
two-and-a-half hours each day on a treadmill, and use a resistance-exercise device where they pull rubberband-like cords attached
to pulleys. Then, when they return to Earth astronauts undergo weeks of rehabilitation to rebuild both bone and muscle tissue.

Exercise Helps Keep Astronauts Health…

Health…

Video : Exercise Helps Keep Astronauts Healthy in Space. This video from NASA explains the importance of exercise in
maintaining the health of astronauts in space.

Fall Prevention
Reducing the number of falls a person has decreases the likelihood of sustaining a fracture. Fairly simple modifications to a
person’s environment, such as installing nightlights, railings on stairs, bars to hold onto in showers, and removing cords and throw
rugs in walking paths can significantly reduce the likelihood of falling. Importantly, people at risk should have their vision and
balance checked frequently.

Secondary Prevention
A person who has undergone a DEXA scan and been diagnosed with osteopenia or osteoporosis has multiple strategies available to
reduce the chances of breaking a bone. These types of treatment strategies are referred to as secondary prevention. The OSG
reports that the primary goals in the prevention and treatment of osteoporosis are to maintain bone health by preventing its loss and
by actually building new [Link] of the Surgeon General. “Bone Health and Osteoporosis: A Report of the Surgeon General.”

[Link].2 [Link]
October, 2004 [Link]/librar...chapter_9.html To accomplish these goals, the OSG recommends a pyramid
approach. The base of the pyramid focuses on balancing nutrition, increasing physical activity, and preventing falls (primary
prevention tactics). The second step in the pyramid is to determine if any underlying disorders or diseases are causing osteoporosis
and to treat them. The third step is pharmacotherapy and involves administering medications. The second and third steps in the
pyramid are secondary prevention tactics.

Secondary Prevention Tactics

We have noted that certain medications and diseases either cause or aggravate osteoporosis. Treating diseases such as
hyperparathyroidism or discontinuing the use of or lowering the dose of medications such as prednisone, substantially reduces the
risk of further deterioration of bone tissue and fracture. (In Section 9.3 of this chapter, you learned the mechanics of how the
parathyroid hormone regulates calcium homeostasis.) When parathyroid hormone is present at continuously high levels in the
blood, it causes a marked elevation in calcium levels. It raises blood calcium levels by increasing osteoclast activity, thereby
increasing bone breakdown and bone loss. Hyperparathyroidism is treated by the surgical removal of the parathyroid gland tumor.
Chronic kidney disease and vitamin D deficiency can also cause an increase in parathyroid hormone levels. When the increase in
parathyroid hormone is the result of disorders in other organs, the condition is referred to as secondary hyperparathyroidism.
Treating diseases such as chronic kidney disease and Crohn’s disease, which are associated with decreased activation of vitamin D,
increased calcium excretion, or malabsorption, is important in people who have not developed osteoporosis yet in order to arrest
further losses in BMD. If these types of conditions exist simultaneously with osteoporosis, it is recommended that both disorders be
treated to prevent further bone deterioration.

Key Takeaways
Osteoporosis is a childhood disease with old-age consequences. Primary prevention of osteoporosis begins early in life with proper
diet and exercise. The strategies of secondary prevention that focus on treating osteoporosis aim to arrest further bone loss and
reduce fracture risk. Osteoporosis prevention and treatment involves a three-tiered approach that incorporates lifestyle
modifications, the assessment and treatment of underlying causes of the disease, and pharmacotherapy.

Discussion Starters
1. Do you or any of your classmates have children? What could a parent of a teenager do to help their child achieve a high peak
bone mass?
2. Discuss the tactics you might employ at your age to maximize your bone health and minimize your risk for developing
osteoporosis.

[Link]: Osteoporosis Prevention and Treatment is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by
LibreTexts.

[Link].3 [Link]
9.3: Phosphorus
Phosphorus’s Functional Role
Phosphorus is present in our bodies as part of a chemical group called a phosphate group. These phosphate groups are essential as a
structural component of cell membranes (as phospholipids), DNA and RNA, energy production (ATP), and regulation of acid-base
homeostasis. Phosphorus however is mostly associated with calcium as a part of the mineral structure of bones and teeth. Blood
phosphorus levels are not controlled as strictly as calcium so the PTH stimulates renal excretion of phosphate so that it does not
accumulate to toxic levels.

Dietary Reference Intakes for Phosphorus

In comparison to calcium, most Americans are not at risk for having a phosphate deficiency. Phosphate is present in many foods
popular in the American diet including meat, fish, dairy products, processed foods, and beverages. Phosphate is added to many
foods because it acts as an emulsifying agent, prevents clumping, improves texture and taste, and extends shelf-life. The average
intake of phosphorus in US adults ranges between 1,000 and 1,500 milligrams per day, well above the RDA of 700 milligrams per
day. The UL set for phosphorous is 4,000 milligrams per day for adults and 3,000 milligrams per day for people over age seventy.
Table : Dietary Reference Intakes for Phosphorus
Age Group RDA (mg/day) UL (mg/day)

Infants (0–6 months) 100* –

Infants (6–12 months) 275* –

Children (1–3 years) 460 3,000

Children (4–8 years) 500 3,000

Children (9–13 years) 1,250 4,000

Adolescents (14–18 years) 1,250 4,000

Adults (19–70 years) 700 4,000

Adults (> 70 years) 700 3,000

* denotes Adequate Intake

Micronutrient Information Center: Phosphorus. Oregon State University, Linus Pauling Institute.
[Link] Updated in July 2013. Accessed October 22, 2017.

Dietary Sources of Phosphorus

Table : Phosphorus Content of Various Foods

9.3.1 [Link]
 Foods Serving Phosphorus (mg) Percent Daily Value 1000

Salmon 3 oz. 315 32

Yogurt, nonfat 8 oz. 306 31

Turkey, light meat 3 oz. 217 22

Chicken, light meat 3 oz. 135 14

Beef 3 oz. 179 18

Lentils* ½ c. 178 18

Almonds* 1 oz. 136 14

Mozzarella 1 oz. 131 13

Peanuts* 1 oz. 108 11

Whole wheat bread 1 slice 68 7

Egg 1 large 86 9

Carbonated cola drink 12 oz. 41 4

Bread, enriched 1 slice 25 3

Micronutrient Information Center: Phosphorus. Oregon State University, Linus Pauling Institute.
[Link] Updated in July 2013. Accessed October 22, 2017.

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[Link]

9.3.2 [Link]
9.4: Magnesium
Magnesium’s Functional Role
Approximately 60 percent of magnesium in the human body is stored in the skeleton, making up about 1 percent of mineralized
bone tissue. Magnesium is not an integral part of the hard mineral crystals, but it does reside on the surface of the crystal and helps
maximize bone structure. Observational studies link magnesium deficiency with an increased risk for osteoporosis. A magnesium-
deficient diet is associated with decreased levels of parathyroid hormone and the activation of vitamin D, which may lead to an
impairment of bone remodeling. A study in nine hundred elderly women and men did show that higher dietary intakes of
magnesium correlated to an increased BMD in the hip.[1] Only a few clinical trials have evaluated the effects of magnesium
supplements on bone health and their results suggest some modest benefits on BMD.
In addition to participating in bone maintenance, magnesium has several other functions in the body. In every reaction involving
the cellular energy molecule, ATP, magnesium is required. More than three hundred enzymatic reactions require magnesium.
Magnesium plays a role in the synthesis of DNA and RNA, carbohydrates, and lipids, and is essential for nerve conduction and
muscle contraction. Another health benefit of magnesium is that it may decrease blood pressure.
Many Americans do not get the recommended intake of magnesium from their diets. Some observational studies suggest mild
magnesium deficiency is linked to increased risk for cardiovascular disease. Signs and symptoms of severe magnesium deficiency
may include tremor, muscle spasms, loss of appetite, and nausea.

Dietary Reference Intakes for Magnesium

The RDAs for magnesium for adults between ages nineteen and thirty are 400 milligrams per day for males and 310 milligrams per
day for females. For adults above age thirty, the RDA increases slightly to 420 milligrams per day for males and 320 milligrams for
females.
Table : Dietary Reference Intakes for Magnesium
Age Group RDA (mg/day) UL from non-food sources (mg/day)

Infants (0–6 months) 30* –

Infants (6–12 months) 75* –

Children (1–3 years) 80 65

Children (4–8 years) 130 110

Children (9–13 years) 240 350

Adolescents (14–18 years) 410 350

Adults (19–30 years) 400 350

Adults (> 30 years) 420 350

* denotes Adequate Intake

Source: Dietary Supplement Fact Sheet: Magnesium. National Institutes of Health, Office of Dietary Supplements.
[Link] Updated July 13, 2009. Accessed November 12, 2017.

Dietary Sources of Magnesium

Magnesium is part of the green pigment, chlorophyll, which is vital for photosynthesis in plants; therefore green leafy vegetables
are a good dietary source for magnesium. Magnesium is also found in high concentrations in fish, dairy products, meats, whole
grains, and nuts. Additionally chocolate, coffee, and hard water contain a good amount of magnesium. Most people in America do
not fulfill the RDA for magnesium in their diets. Typically, Western diets lean toward a low fish intake and the unbalanced
consumption of refined grains versus whole grains.

9.4.1 [Link]
 Table : Magnesium Content of Various Foods

Food Serving Magnesium (mg) Percent Daily Value

Almonds 1 oz. 80 20

Cashews 1 oz. 74 19

Soymilk 1 c. 61 15

Black beans ½ c. 60 15

Edamame ½ c. 50 13

Bread 2 slices 46 12

Avocado 1 c. 44 11

Brown rice ½ c. 42 11

Yogurt 8 oz. 42 11

Oatmeal, instant 1 packet 36 9

Salmon 3 oz. 26 7

Chicken breasts 3 oz. 22 6

Apple 1 medium 9 2

Source: Dietary Supplement Fact Sheet: Magnesium. National Institutes of Health, Office of Dietary Supplements.
[Link] Updated July 13, 2009. Accessed November 12, 2017.

References
1. Tucker KL, Hannan MT, et al.(1994). Potassium, Magnesium, and Fruit and Vegetable Intakes Are Associated with Greater
Bone Mineral Density in Elderly Men and Women. American Journal of Clinical Nutrition, 69(4), 727–36.
[Link]/cgi/pmidlookup?view=long&pmid=10197575. Accessed October 6, 2017. ↵

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[Link]

9.4.2 [Link]
9.5: Summary of Major Minerals
Table : A Summary of the Major Minerals

9.5.1 [Link]
 Recommended Deficiency
Major Groups at risk
Micronutrient Sources Intakes for diseases and Toxicity UL
functions for deficiency
adults symptoms

Component of
Yogurt, Postmenopaus
mineralized
cheese, Increased risk al women,
bone, provides
Calcium sardines, milk, 1,000 mg/day of those who are Kidney stones 2,500 mg
structure and
orange juice, osteoporosis actoseintolera
microarchitect
turnip nt, or vegan
ure

Structural
component of
Salmon,
bones, cell
yogurt, turkey, Bone loss, Older adults,
Phosphorus 700 mg/day membrane, None 3,000 mg
chicken, beef, weak bones alcoholics
DNA and
lentils
RNA, and
ATP

Component of
Whole grains mineralized
and legumes, bone, ATP Alcoholics,
Tremor,
almonds, synthesis and individuals
muscle Nausea,
cashews, utilization, with kidney
Magnesium 420 mg/day spasms, loss vomiting, low 350 mg/day
hazelnuts, carbohydrate, and
of appetite, blood pressure
beets, lipid,protein, gastrointestina
nausea
collards, and RNA, and l disease
kelp DNA
synthesis

Structure of
some vitamins None when
None
Sulfur Protein foods and amino protein needs None None ND
specified
acids, acid- are met
base balance

People
Major positive
consuming too
extracellular
Processed < 2,300 much water,
ion, nerve
foods, table mg/day; Muscle excessive High blood
Sodium transmission, 2,300 mg/day
salt, pork, ideally 1,500 cramps sweating, pressure
muscle
chicken mg/day those with
contraction,
vomiting or
fluid balance
diarrhea

Major positive People

Fruits, intracellular consuming
Irregular
vegetables, ion, nerve diets high in
heartbeat, Abnormal
Potassium legumes, 4700 mg/day transmission, processed ND
muscle heartbeat
whole grains, muscle meats, those
cramps
milk contraction, with vomiting
fluid balance or diarrhea

Chloride Table salt, <3600 Major Unlikely none None 3,600 mg/day
processed mg/day; negative

9.5.2 [Link]
 Recommended Deficiency
Major Groups at risk
Micronutrient Sources Intakes for diseases and Toxicity UL
functions for deficiency
adults symptoms
foods ideally 2300 extracellular
mg/day ion, fluid
balance

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LibreTexts platform.
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9.5.3 [Link]
 CHAPTER OVERVIEW

10: Trace Minerals

Learning Objectives
By the end of this chapter you will be able to:
Describe the functional role, intake recommendations and sources of trace minerals

10.1: Introduction to Trace Minerals

10.2: Iron
10.3: Zinc
10.4: Selenium
10.5: Iodine
10.6: Chromium
10.7: Fluoride
10.8: Summary of Trace Minerals

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1
10.1: Introduction to Trace Minerals
Li‘ili‘i ka ‘ōhiki, loloa ka lua
Small is the crab, large is the hole

Wakame Salad Seaweed Food Cooking by [Link] / CCO

Trace minerals are classified as minerals required in the diet each day in smaller amounts, specifically 100 milligrams or less.
These include copper, zinc, selenium, iodine, chromium, fluoride, manganese, molybdenum, and others. Although trace minerals
are needed in smaller amounts it is important to remember that a deficiency in a trace mineral can be just as detrimental to your
health as a major mineral deficiency. Iodine deficiency is a major concern in countries around the world such as Fiji. In the 1990’s,
almost 50% of the population had signs of iodine deficiency also known as goiter. To combat this national issue, the government of
Fiji banned non-iodized salt and allowed only fortified iodized salt into the country in hopes of increasing the consumption of
iodine in people’s diets. With this law, and health promotion efforts encouraging the consumption of seafood, great progress has
been made in decreasing the prevalence of iodine deficiency in Fiji.[1]

Figure : The Trace Minerals. Image by Allison Calabrese / CC BY 4.0

10.1.1 [Link]
Reference

1. Micronutrient Deficiencies. (2015). Ministry of Health and Medical Services, Shaping Fiji’s Health. [Link]
page_id=1406. Accessed November 12, 2017. ↵

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LibreTexts platform.
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Original source: [Link]

10.1.2 [Link]
10.2: Iron
Red blood cells contain the oxygen-carrier protein hemoglobin. It is composed of four globular peptides, each containing a heme
complex. In the center of each heme, lies iron (Figure 11.2). Iron is needed for the production of other iron-containing proteins such
as myoglobin. Myoglobin is a protein found in the muscle tissues that enhances the amount of available oxygen for muscle
contraction. Iron is also a key component of hundreds of metabolic enzymes. Many of the proteins of the electron-transport chain
contain iron–sulfur clusters involved in the transfer of high-energy electrons and ultimately ATP synthesis. Iron is also involved in
numerous metabolic reactions that take place mainly in the liver and detoxify harmful substances. Moreover, iron is required for
DNA synthesis. The great majority of iron used in the body is that recycled from the continuous breakdown of red blood cells.

Figure : The Structure of Hemoglobin. Image

by Allison Calabrese / CC BY 4.0
Hemoglobin is composed of four peptides. Each contains a heme group with iron in the center.
The iron in hemoglobin binds to oxygen in the capillaries of the lungs and transports it to cells where the oxygen is released. If iron
level is low hemoglobin is not synthesized in sufficient amounts and the oxygen-carrying capacity of red blood cells is reduced,
resulting in anemia. When iron levels are low in the diet the small intestine more efficiently absorbs iron in an attempt to
compensate for the low dietary intake, but this process cannot make up for the excessive loss of iron that occurs with chronic blood
loss or low intake. When blood cells are decommissioned for use, the body recycles the iron back to the bone marrow where red
blood cells are made. The body stores some iron in the bone marrow, liver, spleen, and skeletal muscle. A relatively small amount
of iron is excreted when cells lining the small intestine and skin cells die and in blood loss, such as during menstrual bleeding. The
lost iron must be replaced from dietary sources.
The bioavailability of iron is highly dependent on dietary sources. In animal-based foods about 60 percent of iron is bound to
hemoglobin, and heme iron is more bioavailable than nonheme iron. The other 40 percent of iron in animal-based foods is
nonheme, which is the only iron source in plant-based foods. Some plants contain chemicals (such as phytate, oxalates, tannins, and
polyphenols) that inhibit iron absorption. Although, eating fruits and vegetables rich in vitamin C at the same time as iron-
containing foods markedly increases iron absorption. A review in the American Journal of Clinical Nutrition reports that in
developed countries iron bioavailability from mixed diets ranges between 14 and 18 percent, and that from vegetarian diets ranges
between 5 and 12 percent.[1] Vegans are at higher risk for iron deficiency, but careful meal planning does prevent its development.
Iron deficiency is the most common of all micronutrient deficiencies.
Table : Enhancers and Inhibitors of Iron Absorption

10.2.1 [Link]
 Enhancer Inhibitor

Meat Phosphate

Fish Calcium

Poultry Tea

Seafood Coffee

Stomach acid Colas

Soy protein

High doses of minerals (antacids)

Bran/fiber

Phytates

Oxalates

Polyphenols

Figure : Iron Absorption, Functions,

and Loss. Image by Allison Calabrese / CC BY 4.0

Iron Toxicity
The body excretes little iron and therefore the potential for accumulation in tissues and organs is considerable. Iron accumulation in
certain tissues and organs can cause a host of health problems in children and adults including extreme fatigue, arthritis, joint pain,
and severe liver and heart toxicity. In children, death has occurred from ingesting as little as 200 mg of iron and therefore it is
critical to keep iron supplements out of children’s reach. The IOM has set tolerable upper intake levels of iron (Table ).
Mostly a hereditary disease, hemochromatosis is the result of a genetic mutation that leads to abnormal iron metabolism and an
accumulation of iron in certain tissues such as the liver, pancreas, and heart. The signs and symptoms of hemochromatosis are

10.2.2 [Link]
similar to those of iron overload in tissues caused by high dietary intake of iron or other non-genetic metabolic abnormalities, but
are often increased in severity.

Dietary Reference Intakes for Iron

Table : Dietary Reference Intakes for Iron

Age Group RDA(mg/day) UL(mg/day)

Infant (0–6 months) 0.27* 40

Infants (6–12 months) 11* 40

Children (1–3 years) 7 40

Children (4–8 years) 10 40

Children (9–13 years) 8 40

Adolescents (14–18 years) 11 (males), 15 (females) 45

Adults (19–50 years) 8 (males), 18 (females) 45

Adults (> 50 years) 8 45

* denotes Adequate Intake

Dietary Sources of Iron

Table : Iron Content of Various Foods

Food Serving Iron (mg) Percent Daily Value

Breakfast cereals, fortified 1 serving 18 100

Oysters 3 oz. 8 44

Dark chocolate 3 oz. 7 39

Beef liver 3 oz. 5 28

Lentils ½ c. 3 17

Spinach, boiled ½ c. 3 17

Tofu, firm ½ c. 3 17

Kidney beans ½ c. 2 11

Sardines 3 oz. 2 11

Iron-Deficiency Anemia
Iron-deficiency anemia is a condition that develops from having insufficient iron levels in the body resulting in fewer and smaller
red blood cells containing lower amounts of hemoglobin. Regardless of the cause (be it from low dietary intake of iron or via
excessive blood loss), iron-deficiency anemia has the following signs and symptoms, which are linked to the essential functions of
iron in energy metabolism and blood health:
Fatigue
Weakness
Pale skin
Shortness of breath

10.2.3 [Link]
 Dizziness
Swollen, sore tongue
Abnormal heart rate
Iron-deficiency anemia is diagnosed from characteristic signs and symptoms and confirmed with simple blood tests that count red
blood cells and determine hemoglobin and iron content in blood. Anemia is most often treated with iron supplements and
increasing the consumption of foods that are higher in iron. Iron supplements have some adverse side effects including nausea,
constipation, diarrhea, vomiting, and abdominal pain. Reducing the dose at first and then gradually increasing to the full dose often
minimizes the side effects of iron supplements. Avoiding foods and beverages high in phytates and also tea (which contains tannic
acid and polyphenols, both of which impair iron absorption), is important for people who have iron-deficiency anemia. Eating a
dietary source of vitamin C at the same time as iron-containing foods improves absorption of nonheme iron in the gut. Additionally,
unknown compounds that likely reside in muscle tissue of meat, poultry, and fish increase iron absorption from both heme and
nonheme sources. See Table 17.2 for more enhancers and inhibitors for iron absorption.

Iron Deficiency: A Worldwide Nutritional Health Problem

The Centers for Disease Control and Prevention reports that iron deficiency is the most common nutritional deficiency worldwide.
[2]
The WHO estimates that 80 percent of people are iron deficient and 30 percent of the world population has iron-deficiency
anemia.[3] The main causes of iron deficiency worldwide are parasitic worm infections in the gut causing excessive blood loss, and
malaria, a parasitic disease causing the destruction of red blood cells. In the developed world, iron deficiency is more the result of
dietary insufficiency and/or excessive blood loss occurring during menstruation or childbirth.

At-Risk Populations
Infants, children, adolescents, and women are the populations most at risk worldwide for iron-deficiency anemia by all causes.
Infants, children, and even teens require more iron because iron is essential for growth. In these populations, iron deficiency (and
eventually iron-deficiency anemia) can also cause the following signs and symptoms: poor growth, failure to thrive, and poor
performance in school, as well as mental, motor, and behavioral disorders. Women who experience heavy menstrual bleeding or
who are pregnant require more iron in the diet. One more high-risk group is the elderly. Both elderly men and women have a high
incidence of anemia and the most common causes are dietary iron deficiency and chronic disease such as ulcer, inflammatory
diseases, and cancer. Additionally, those who have recently suffered from traumatic blood loss, frequently donate blood, or take
excessive antacids for heartburn need more iron in the diet.

Preventing Iron-Deficiency Anemia

In young children iron-deficiency anemia can cause significant motor, mental, and behavioral abnormalities that are long-lasting. In
the United States, the high incidence of iron-deficiency anemia in infants and children was a major public-health problem prior to
the early 1970s, but now the incidence has been greatly reduced. This achievement was accomplished by implementing the
screening of infants for iron-deficiency anemia in the health sector as a common practice, advocating the fortification of infant
formulas and cereals with iron, and distributing them in supplemental food programs, such as that within Women, Infants, and
Children (WIC). Breastfeeding, iron supplementation, and delaying the introduction of cow’s milk for at least the first twelve
months of life were also encouraged. These practices were implemented across the socioeconomic spectrum and by the 1980s iron-
deficiency anemia in infants had significantly declined. Other solutions had to be introduced in young children, who no longer were
fed breast milk or fortified formulas and were consuming cow’s milk. The following solutions were introduced to parents: provide
a diet rich in sources of iron and vitamin C, limit cow’s milk consumption to less than twenty-four ounces per day, and a
multivitamin containing iron.
In the third world, iron-deficiency anemia remains a significant public-health challenge. The World Bank claims that a million
deaths occur every year from anemia and that the majority of those occur in Africa and Southeast Asia. The World Bank states five
key interventions to combat anemia:[4]
Provide at-risk groups with iron supplements.
Fortify staple foods with iron and other micronutrients whose deficiencies are linked with anemia.
Prevent the spread of malaria and treat the hundreds of millions with the disease.
Provide insecticide-treated bed netting to prevent parasitic infections.

10.2.4 [Link]
 Treat parasitic-worm infestations in high-risk populations.
Also, there is ongoing investigation as to whether supplying iron cookware to at-risk populations is effective in preventing and
treating iron-deficiency anemia.

References
1. Centers for Disease Control and Prevention. “Iron and Iron Deficiency.” Accessed October 2, 2011.
[Link]/nutrition/everyone/basics/vitamins/[Link]. ↵
2. Iron and Iron Deficiency. Centers for Disease Control and Prevention.
[Link]/nutrition/everyone/basics/vitamins/[Link] October 2, 2011. ↵
3. Anemia. The World Bank.
[Link]/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTPHAAG/0,,content
MDK:20588506~menuPK:1314803~pagePK:64229817~piPK:64229743 ~theSitePK:672263,[Link]. Accessed October 2,
2011. ↵
4. Anemia. The World Bank. [Link]/WBSITE/EXTE...~piPK:64229743 ~theSitePK:672263,[Link]. Accessed
October 2, 2011. ↵

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[Link]

10.2.5 [Link]
10.3: Zinc
Zinc is a cofactor for over two hundred enzymes in the human body and plays a direct role in RNA, DNA, and protein synthesis.
Zinc also is a cofactor for enzymes involved in energy metabolism. As the result of its prominent roles in anabolic and energy
metabolism, a zinc deficiency in infants and children blunts growth. The reliance of growth on adequate dietary zinc was
discovered in the early 1960s in the Middle East where adolescent nutritional dwarfism was linked to diets containing high
amounts of phytate. Cereal grains and some vegetables contain chemicals, one being phytate, which blocks the absorption of zinc
and other minerals in the gut. It is estimated that half of the world’s population has a zinc-deficient diet.[1]
This is largely a consequence of the lack of red meat and seafood in the diet and reliance on cereal grains as the main dietary staple.
In adults, severe zinc deficiency can cause hair loss, diarrhea, skin sores, loss of appetite, and weight loss. Zinc is a required
cofactor for an enzyme that synthesizes the heme portion of hemoglobin and severely deficient zinc diets can result in anemia.

Dietary Reference Intakes for Zinc

Table : DDietary Reference Intakes for Zinc

Age Group RDA(mg/day) UL(mg/day)

Infant (0–6 months) 2* 4

Infants (6–12 months) 3 5

Children (1–3 years) 3 7

Children (4–8 years) 5 12

Children (9–13 years) 8 23

Adolescents (14–18 years) 11 (males), 9 (females) 34

Adults (19 + years) 11 (males), 8 (females) 40

* denotes Adequate Intake

Fact Sheet for Health Professionals: Zinc. National Institute of Health, Office of Dietary Supplements.
[Link] Updated February 11, 2016. Accessed November 10, 2017.

Dietary Sources of Zinc

Table : Zinc Content of Various Foods
Food Serving Zinc (mg) Percent Daily Value

Oysters 3 oz. 74 493

Beef, chuck roast 3 oz. 7 47

Crab 3 oz. 6.5 43

Lobster 3 oz. 3.4 23

Pork loin 3 oz. 2.9 19

Baked beans ½ c. 2.9 19

Yogurt, low fat 8 oz. 1.7 11

Oatmeal, instant 1 packet 1.1 7

Almonds 1 oz. 0.9 6

10.3.1 [Link]
Fact Sheet for Health Professionals: Zinc. National Institute of Health, Office of Dietary Supplements.
[Link] Updated February 11, 2016. Accessed November 10, 2017.

References
1. Prasad, Ananda. (2003). Zinc deficiency. British Medical Journal, 326(7386), 409–410. doi: 10.1136/bmj.326.7386.409.
Accessed October 2, 2011. [Link] ↵

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[Link]

10.3.2 [Link]
10.4: Selenium
Selenium is a cofactor of enzymes that release active thyroid hormone in cells and therefore low levels can cause similar signs and
symptoms as iodine deficiency. The other important function of selenium is as an antioxidant.

Selenium Functions and Health Benefits

Around twenty-five known proteins require selenium to function. Some are enzymes involved in detoxifying free radicals and
include glutathione peroxidases and thioredoxin reductase. As an integral functioning part of these enzymes, selenium aids in the
regeneration of glutathione and oxidized vitamin C. Selenium as part of glutathione peroxidase also protects lipids from free
radicals, and, in doing so, spares vitamin E. This is just one example of how antioxidants work together to protect the body against
free-radical induced damage. Other functions of selenium-containing proteins include protecting endothelial cells that line tissues,
converting the inactive thyroid hormone to the active form in cells, and mediating inflammatory and immune system responses.
Observational studies have demonstrated that selenium deficiency is linked to an increased risk of cancer. A review of forty-nine
observational studies published in the May 2011 issue of the Cochrane Database of Systematic Reviews concluded that higher
selenium exposure reduces overall cancer incidence by about 34 percent in men and 10 percent in women, but notes these studies
had several limitations, including data quality, bias, and large differences among different studies.[1] Additionally, this review states
that there is no convincing evidence from six clinical trials that selenium supplements reduce cancer risk.
Because of its role as a lipid protector, selenium has been suspected to prevent cardiovascular disease. In some observational
studies, low levels of selenium are associated with a decreased risk of cardiovascular disease. However, other studies have not
always confirmed this association and clinical trials are lacking.

Figure : Selenium’s Role in Detoxifying Free Radicals. Image by Allison

Calabrese / CC BY 4.0

Dietary Reference Intakes for Selenium

The IOM has set the RDAs for selenium based on the amount required to maximize the activity of glutathione peroxidases found in
blood plasma. The RDAs for different age groups are listed in Table .
Table : Dietary Reference Intakes for Selenium

10.4.1 [Link]
 Age Group RDA Males and Females mcg/day UL

Infants (0–6 months) 15* 45

Infants (7–12 months) 20* 65

Children (1–3 years) 20 90

Children (4–8 years) 30 150

Children (9–13 years) 40 280

Adolescents (14–18 years) 55 400

Adults (> 19 years) 55 400

*denotes Adequate Intake

Selenium at doses several thousand times the RDA can cause acute toxicity, and when ingested in gram quantities can be fatal.
Chronic exposure to foods grown in soils containing high levels of selenium (significantly above the UL) can cause brittle hair and
nails, gastrointestinal discomfort, skin rashes, halitosis, fatigue, and irritability. The IOM has set the UL for selenium for adults at
400 micrograms per day.

Dietary Sources of Selenium

Organ meats, muscle meats, and seafood have the highest selenium content. Plants do not require selenium, so the selenium content
in fruits and vegetables is usually low. Animals fed grains from selenium-rich soils do contain some selenium. Grains and some
nuts contain selenium when grown in selenium-containing soils. See Table 11.7 “Selenium Contents of Various Foods” for the
selenium content of various foods.
Table : Selenium Contents of Various Foods

Food Serving Selenium (mcg) Percent Daily Value

Brazil nuts 1 oz. 544 777

Shrimp 3 oz. 34 49

Crab meat 3 oz. 41 59

Ricotta cheese 1 c. 41 59

Salmon 3 oz. 40 57

Pork 3 oz. 35 50

Ground beef 3 oz. 18 26

Round steak 3 oz. 28.5 41

Beef liver 3 oz. 28 40

Chicken 3 oz. 13 19

Whole-wheat bread 2 slices 23 33

Couscous 1 c. 43 61

Barley, cooked 1 c. 13.5 19

Milk, low-fat 1 c. 8 11

Walnuts, black 1 oz. 5 7

10.4.2 [Link]
Source: US Department of Agriculture, Agricultural Research Service. 2010. USDA National Nutrient Database for Standard
Reference, Release 23. [Link]

References
1. Dennert G, Zwahlen M, et al. (2011). Selenium for Preventing Cancer. Cochrane Database of Systematic
Reviews,[Link]://[Link]/pubmed/21563143. Accessed November 22, 2017. ↵

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[Link]

10.4.3 [Link]
10.5: Iodine
Recall the discovery of iodine and its use as a means of preventing goiter, a gross enlargement of the thyroid gland in the neck.
Iodine is essential for the synthesis of thyroid hormone, which regulates basal metabolism, growth, and development. Low iodine
levels and consequently hypothyroidism has many signs and symptoms including fatigue, sensitivity to cold, constipation, weight
gain, depression, and dry, itchy skin and paleness. The development of goiter may often be the most visible sign of chronic iodine
deficiency, but the consequences of low levels of thyroid hormone can be severe during infancy, childhood, and adolescence as it
affects all stages of growth and development.

Figure : Iodine Deficiency: Goiter. A large goiter by Dr. [Link],

India / CC BY-SA 3.0
Thyroid hormone plays a major role in brain development and growth and fetuses and infants with severe iodine deficiency
develop a condition known as cretinism, in which physical and neurological impairment can be severe. The World Health
Organization (WHO) estimates iodine deficiency affects over two billion people worldwide and it is the number-one cause of
preventable brain damage worldwide.[1]

Figure : Deaths Due to Iodine Deficiency

Worldwide in 2012. Image by Chris55 / CC BY 4.0

Dietary Reference Intakes for Iodine

Table : Dietary Reference Intakes for Iodine

10.5.1 [Link]
 Age Group RDA Males and Females mcg/day UL

Infants (0–6 months) 110*

Infants (7–12 months) 130*

Children (1–3 years) 90 200

Children (4–8 years) 120 300

Children (9–13 years) 150 600

Adolescents (14–18 years) 150 900

Adults (> 19 years) 150 1,100

*denotes Adequate Intake

Health Professional Fact Sheet: Iodine. National Institute of Health, Office of Dietary Supplements.
[Link] Updated June 24, 2011. Accessed November 10, 2017.

Dietary Sources of Iodine

The mineral content of foods is greatly affected by the soil from which it grew, and thus geographic location is the primary
determinant of the mineral content of foods. For instance, iodine comes mostly from seawater so the greater the distance from the
sea the lesser the iodine content in the soil.
Table : Iodine Content of Various Foods

Food Serving Iodine (mcg) Percent Daily Value

Seaweed 1 g. 16 to 2,984 11 to 1,989

Cod fish 3 oz. 99 66

Yogurt, low fat 8 oz. 75 50

Iodized salt 1.5 g. 71 47

Milk, reduced fat 8 oz. 56 37

Ice cream, chocolate ½ c. 30 20

Egg 1 large 24 16

Tuna, canned 3 oz. 17 11

Prunes, dried 5 prunes 13 9

Banana 1 medium 3 2

Health Professional Fact Sheet: Iodine. National Institute of Health, Office of Dietary Supplements.
[Link] Updated June 24, 2011. Accessed November 10, 2017.

References
1. World Health Organization. “Iodine Status Worldwide.” Accessed October 2, 2011.
[Link] ↵

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10.5.2 [Link]
10.5.3 [Link]
10.6: Chromium
The functioning of chromium in the body is less understood than that of most other minerals. It enhances the actions of insulin so it
plays a role in carbohydrate, fat, and protein metabolism. Currently, the results of scientific studies evaluating the usefulness of
chromium supplementation in preventing and treating Type 2 diabetes are largely inconclusive. More research is needed to better
determine if chromium is helpful in treating certain chronic diseases and, if so, at what doses. If a deficiency of chromium occurs in
the body, signs and symptoms include weight loss, peripheral neuropathy, elevated plasma glucose concentrations or impaired
glucose use, and high plasma free fatty acid concentrations. Although toxicity of the mineral is a low risk in humans, it can cause
DNA damage, organ damage, and renal problems. Tissues that are high in chromium include the liver, spleen, and bone.[1]

Dietary Reference Intakes for Chromium

The recommended intake for chromium is 35 mcg per day for adult males and 25 mcg per day for adult females. There is
insufficient evidence to establish an UL for chromium.
Table : Dietary Reference Intakes for Chromium

Age Group AI (μg/day)

Infants (0-6 months) 0.2

Infants (6-12 months) 5.5

Children (1-3 years) 11

Children (4-8 years) 15

Children (9-13 years) 25 (males), 21 (females)

Adolescents (14-18 years) 35 (males), 24 (females)

Adults (19-50 years) 35 (males), 25 (females)

Adults (>50 years) 30 (males), 20 (females)

Source: The National Academies Press (2006). Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. The
National Academies of Sciences Engineering Medicine. 296. Dietary Sources For Chromium: Dietary sources of chromium include
meats, nuts, and whole grains. [2]

Refernces
1. Gropper, S. A. S., Smith, J. L., & Carr, T. P. (2018). Advanced nutrition and human metabolism. Boston, MA: Cengage
Learning. ↵
2. Anderson, R. A., Bryden, N. A., & Polansky, M. M. (1992). Dietary chromium intake. Freely chosen diets, institutional diet,
and individual foods. Biological Trace Element Research, 32, 117–121. [Link] Accessed
December 5, 2019. ↵

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10.6.1 [Link]
10.7: Fluoride
Fluoride’s Functional Role
Fluoride is known mostly as the mineral that combats tooth decay. It assists in tooth and bone development and maintenance.
Fluoride combats tooth decay via three mechanisms:
1. Blocking acid formation by bacteria
2. Preventing demineralization of teeth
3. Enhancing remineralization of destroyed enamel
Fluoride was first added to drinking water in 1945 in Grand Rapids, Michigan; now over 60 percent of the US population
consumes fluoridated drinking water. The Centers for Disease Control and Prevention (CDC) has reported that fluoridation of water
prevents, on average, 27 percent of cavities in children and between 20 and 40 percent of cavities in adults. The CDC considers
water fluoridation one of the ten great public health achievements in the twentieth century[1].
The optimal fluoride concentration in water to prevent tooth decay ranges between 0.7–1.2 milligrams per liter. Exposure to
fluoride at three to five times this concentration before the growth of permanent teeth can cause fluorosis, which is the mottling and
discoloring of the teeth.

Figure : A Severe Case of Fluorosis. Bellingham fluorosis by Editmore / Public Domain

Fluoride’s benefits to mineralized tissues of the teeth are well substantiated, but the effects of fluoride on bone are not as well
known. Fluoride is currently being researched as a potential treatment for osteoporosis. The data are inconsistent on whether
consuming fluoridated water reduces the incidence of osteoporosis and fracture risk. Fluoride does stimulate osteoblast bone
building activity, and fluoride therapy in patients with osteoporosis has been shown to increase BMD. In general, it appears that at
low doses, fluoride treatment increases BMD in people with osteoporosis and is more effective in increasing bone quality when the
intakes of calcium and vitamin D are adequate. The Food and Drug Administration has not approved fluoride for the treatment of
osteoporosis mainly because its benefits are not sufficiently known and it has several side effects including frequent stomach upset
and joint pain. The doses of fluoride used to treat osteoporosis are much greater than that in fluoridated water.

Dietary Reference Intake

The IOM has given Adequate Intakes (AI) for fluoride, but has not yet developed RDAs. The AIs are based on the doses of fluoride
shown to reduce the incidence of cavities, but not cause dental fluorosis. From infancy to adolescence, the AIs for fluoride increase
from 0.01 milligrams per day for ages less than six months to 2 milligrams per day for those between the ages of fourteen and
eighteen. In adulthood, the AI for males is 4 milligrams per day and for females is 3 milligrams per day. The UL for young children
is set at 1.3 and 2.2 milligrams per day for girls and boys, respectively. For adults, the UL is set at 10 milligrams per day.
Table : Dietary Reference Intakes for Fluoride

10.7.1 [Link]
 Age Group AI (mg/day) UL (mg/day)

Infants (0–6 months) 0.01 0.7

Infants (6–12 months) 0.50 0.9

Children (1–3 years) 0.70 1.3

Children (4–8 years) 1.00 2.2

Children (9–13 years) 2.00 10.0

Adolescents (14–18 years) 3.00 10.0

Adult Males (> 19 years) 4.00 10.0

Adult Females (> 19 years) 3.00 10.0

Source: Institute of Medicine. (1997). Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. .
[Link]/Reports/1997/Diet...-[Link].

Dietary Sources of Fluoride

Greater than 70 percent of a person’s fluoride comes from drinking fluoridated water when they live in a community that
fluoridates the drinking water. Other beverages with a high amount of fluoride include teas and grape juice. Solid foods do not
contain a large amount of fluoride. Fluoride content in foods depends on whether it was grown in soils and water that contained
fluoride or cooked with fluoridated water. Canned meats and fish that contain bones do contain some fluoride.
Table : Fluoride Content of Various Foods

Food Serving Fluoride (mg) Percent Daily Value*

Fruit Juice 3.5 fl oz. 0.02-2.1 0.7-70

Crab, canned 3.5 oz. 0.21 7

Rice, cooked 3.5 oz. 0.04 1.3

Fish, cooked 3.5 oz. 0.02 0.7

Chicken 3.5 oz. 0.015 0.5

* Current AI used to determine

Percent Daily Value

Micronutrient Information Center: Fluoride. Oregon State University, Linus Pauling Institute.
[Link]/mic/minerals/fluoride . Updated in April 29, 2015. Accessed October 22, 2017.

References
1. 10 Great Public Health Achievements in the 20th Century. (1999). Centers for Disease Control, Morbidity and Mortality Weekly
Report, 48(12), 241–43. [Link]/about/history/[Link]. Accessed November 22, 2017. ↵

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[Link]

10.7.2 [Link]
10.8: Summary of Trace Minerals
Table : Summary of the Trace Minerals

10.8.1 [Link]
 Recommended Deficiency
Major Groups at risk
Micronutrient Sources Intakes for diseases and Toxicity UL
Functions for deficiency
adults symptoms

Infants and
Assists in
Red meat, egg preschool
energy
yolks, dark Anemia: children,
production, Liver damage,
leafy fatigue, adolescents,
DNA increased risk
Iron vegetables, 8-18 mg/day paleness, women, 45 mg/day
synthesis of diabetes
dried fruit, faster heart pregnant
required for and cancer
iron-fortified rate women,
red blood cell
foods athletes,
function
vegetarians

Assists in Anemia:
Those who Vomiting,
Nuts, seeds, energy fatigue,
consume abdominal
Copper whole grains, 900 mcg/day production, paleness, 10 mg/day
excessive zinc pain, diarrhea,
seafood iron faster heart
supplements liver damage
metabolism rate

Assists in
Growth
Oysters, wheat energy
retardation in
germ, production,
children, hair
pumpkin protein, RNA Depressed
loss, diarrhea, Vegetarians,
Zinc seeds, squash,, 8-11 mg/day and DNA immune 40 mg/day
skin sores, older adults
beans, sesame synthesis; function
loss of
seeds, tahini, required for
appetite,
beef, lamb hemoglobinsy
weight loss
nthesis

Fatigue,
Essential for Populations Nausea,
muscle pain,
Meat, seafood, thyroid where the soil diarrhea,
Selenium 55 mcg/day weakness, 400 mcg/day
eggs, nuts hormone is low in vomiting,
Keshan
activity selenium fatigue
disease

Goiter,
cretinism,
Making other signs Populations
thyroid and symptoms where the soil
Iodized salt,
hormone, include is low in Enlarged
Iodine seaweed, dairy 150 mcg/day 1110 mcg/day
metabolism, fatigue, iodine, and thyroid
products
growth and depression, iodized salt is
development weight gain, not used
itchy skin, low
heart-rate

Assists insulin
in
Meats, nuts abnormal
25-35 carbohydrate, Malnourished
Chromium and whole glucose None ND
mcg/day lipid and children
grain metabolism
protein
metabolism

Fluoride Fluoridated 3-4 mg/day Component of Increased risk Populations Fluorosismottl 10 mg/day

10.8.2 [Link]
 Recommended Deficiency
Major Groups at risk
Micronutrient Sources Intakes for diseases and Toxicity UL
Functions for deficiency
adults symptoms
water, foods mineralized of dental with non ed teeth,
prepared in bone, provides caries fluoridated kidneydamage
fluoridated structure and water
water, seafood microarchitect
ure, stimulates
new bone
growth

Impaired
growth,
Legumes, Glucose
skeletal
nuts, leafy 1.8-2.3 synthesis,
Manganese abnormalities, None Nerve damage 11 mg/day
green mg/day amino-acid
abnormal
vegetables catabolism
glucose
metabolism

Cofactor for a
Milk, grains, Arthritis, joint
Molybdenum 45 mcg/day number of Unknown None 2 mg/day
legumes inflammation
enzymes

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10.8.3 [Link]
 CHAPTER OVERVIEW

11: Food Safety

Learning Objectives
By the end of this chapter you will be able to:
Describe the major types and causes of and contamination
Describe the purpose and process of food irradiation
Describe consumer-level techniques for avoiding foodborne illness

11.1: Introduction to Food Safety

11.2: The Major Types of Foodborne Illness
11.3: The Causes of Food Contamination
11.4: Protecting the Public Health
11.5: The Food System
11.6: Food Preservation
11.7: Food Processing
11.8: The Effect of New Technologies
11.9: Efforts on the Consumer Level- What You Can Do

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1
11.1: Introduction to Food Safety
Ka lepo ke kumu wai, e hua‘i ana ka lepo kai
When the source of water is dirty, the dirt is carried to the sea.

Figure : Image by Maarten Van de Heuvel on [Link] / CCO

Foodborne Illness and Food Safety

Foodborne illness is a serious threat to health. Sometimes called “food poisoning,” foodborne illness is a common public health
problem that can result from exposure to a pathogen or a toxin via food or beverages. Raw foods, such as seafood, produce, and
meats, can all be contaminated during harvest (or slaughter for meats), processing, packaging, or during distribution, though meat
and poultry are the most common source of foodborne illness. For all kinds of food, contamination also can occur during
preparation and cooking in a home kitchen or in a restaurant. For example in 2009, the Marshall Islands reported 174 cases
presenting with vomiting and diarrhea. After an epidemiological investigation was completed, they identified the cause to be egg
sandwiches that had been left at room temperature too long resulting in the growth of foodborne toxins in the egg sandwiches.[1]
In many developing nations, contaminated water is also a major source of foodborne illness. Many people are affected by
foodborne illness each year, making food safety a very important issue. Annually, one out of six Americans becomes sick after
consuming contaminated foods or beverages.[2] Foodborne illness can range from mild stomach upset to severe symptoms, or even
fatalities. The problem of food contamination can not only be dangerous to your health, it can also be harmful to your wallet.
Medical costs and lost wages due to salmonellosis, just one foodborne disease, are estimated at over $1 billion per year.

At-Risk Groups
No one is immune from consuming contaminated food but, whether you become seriously ill depends on the microorganism, the
amount you have consumed, and your overall health. In addition, some groups have a higher risk than others for developing severe
complications to foodborne disease. Who is most at risk? Young children, elderly people, and pregnant women all have a higher
chance of becoming very sick after consuming contaminated food. Other high-risk groups include people with compromised
immune systems due to HIV/AIDS, immunosuppressive medications (such as after an organ transplant), and long-term steroid use
for asthma or arthritis. Exposure to contaminated food could also pose problems for diabetics, cancer patients, people who have
liver disease, and people who have stomach problems as a result of low stomach acid or previous stomach surgery. People in all of
these groups should handle food carefully, make sure that what they eat has been cooked thoroughly, and avoid taking any chances
that could lead to exposure.

Learning Activities
1. Thein CC, Trinidad RM, Pavlin B. (2010). A Large Foodborne Outbreak on a Small Pacific Island. Pacific Health Dialogue,
16(1). [Link] Accessed January 28, 2018. ↵

11.1.1 [Link]
 2. Foodborne Illnesses and Germs. (2018). Centers for Disease Control and
[Link]://[Link]/foodsafety/[Link] . Updated January 23, 2018. Accessed January 28, 2017. ↵

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11.1.2 [Link]
11.2: The Major Types of Foodborne Illness
Foodborne illnesses are either infectious or toxic in nature. The difference depends on the agent that causes the condition.
Microbes, such as bacteria, cause food infections, while toxins, such as the kind produced by molds, cause intoxications. Different
diseases manifest in different ways, so signs and symptoms can vary with the source of contamination. However the illness occurs,
the microbe or toxin enters the body through the gastrointestinal tract, and as a result common symptoms include diarrhea, nausea,
and abdominal pain. Additional symptoms may include vomiting, dehydration, lightheadedness, and rapid heartbeat. More severe
complications can include a high fever, diarrhea that lasts more than three days, prolonged vomiting, bloody stools, and signs of
shock.
One of the biggest misconceptions about foodborne illness is that it is always triggered by the last meal that a person ate. However,
it may take several days or more before the onset of symptoms. If you develop a foodborne illness, you should rest and drink plenty
of fluids. Avoid antidiarrheal medications, because they could slow the elimination of the contaminant.

Food Infection
According to the CDC, more than 250 different foodborne diseases have been identified.[1] Majority of these diseases are food
infections, which means they are caused from food contaminated by microorganisms, such as bacteria, by microscopic animals
called parasites, or by viruses. The infection then grows inside the body and becomes the source of symptoms. Food infections can
be sporadic and often are not reported to physicians. However, occasional outbreaks occur that put communities, states and
provinces, or even entire nations at risk. For example, in 1994, an outbreak of the infection salmonellosis occurred in the United
States due to contaminated ice cream. An estimated 224,000 people became ill. In 1988, contaminated clams resulted in an
outbreak of hepatitis A in China, which affected about 300,000 people.[2]

The Reproduction of Microorganisms

Bacteria, one of the most common agents of food infection, are single-celled microorganisms that are too small to be seen with the
human eye. Microbes live, die, and reproduce, and like all living creatures, they depend on certain conditions to survive and thrive.
In order to reproduce within food, microorganisms require the following:
Temperature. Between 40°F and 140°F, which is called the danger zone, bacteria grow rapidly.
Time. More than two hours in the danger zone.
Water. High moisture content is helpful. Fresh fruits and vegetables have the highest moisture content.
Oxygen. Most microorganisms need oxygen to grow and multiply, but a few are anaerobic and do not.
Acidity and pH Level. Foods that have a low level of acidity (or a high pH level) provide an ideal environment, since most
microorganisms grow best around pH 7.0 and not many will grow below pH 4.0 . Examples of higher pH foods include egg,
meat, seafood, milk, and corn. Examples of low pH foods include citrus fruits, sauerkraut, tomatoes, and pineapples.
Nutrient Content. Microorganisms need protein, starch, sugars, fats, and other compounds to grow. Typically high-protein foods
are better for bacterial growth.

Food Intoxication
Other kinds of foodborne illness are food intoxications, which are caused by natural toxins or harmful chemicals. These and other
unspecified agents are major contributors to episodes of acute gastroenteritis and other kinds of foodborne illness.[3] Like
pathogens, toxins and chemicals can be introduced to food during cultivation, harvesting, processing, or distribution. Some toxins
can lead to symptoms that are also common to food infection, such as abdominal cramping, while others can cause different kinds
of symptoms and complications, some very severe. For example, mercury, which is sometimes found in fish, can cause
neurological damage in infants and children. Exposure to cadmium can cause kidney damage, typically in elderly people.

Learning Activities
1. Foodborne Illnesses and Germs. (2018). Centers for Disease Control and
[Link]://[Link]/foodsafety/[Link] . Updated January 23, 2018. Accessed January 28, 2017. ↵
2. Food Safety. (2017). World Health Organization. [Link]/mediacentre/factsheets/fs399/en/. Updated October 2017.
Accessed January 18, 2018. ↵

11.2.1 [Link]
 3. Scallan E, Griffin PM, Angulo FJ, et al. (2011). Foodborne Illness Acquired in the United States—Unspecified Agents.
Emerging Infectious Diseases, 17(1):16-22. [Link] Accessed January 28,
2018. ↵

This page titled 11.2: The Major Types of Foodborne Illness is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or
curated by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
17.2: The Major Types of Foodborne Illness by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-
NC-SA 4.0. Original source: [Link]

11.2.2 [Link]
11.3: The Causes of Food Contamination
Both food infections and food intoxications can create a burden on health systems, when patients require treatment and support,
and on food systems, when companies must recall contaminated food or address public concerns. It all begins with the agent that
causes the contamination. When a person ingests a food contaminant, it travels to the stomach and intestines. There, it can interfere
with the body’s functions and make you sick. In the next part, we will focus on different types of food contaminants and examine
common microbes, toxins, chemicals, and other substances that can cause food infections and intoxications. Let’s begin with
pathogens, which include bacteria and viruses. About one hundred years ago, typhoid fever, tuberculosis, and cholera were
common diseases caused by food and water contaminated by pathogens. Over time, improvements in food processing and water
treatment eliminated most of those problems in North America. Today, other bacteria and viruses have become common causes of
food infection.

Bacteria
All foods naturally contain small amounts of bacteria. However, poor handling and preparation of food, along with improper
cooking or storage can multiply bacteria and cause illness. In addition, bacteria can multiply quickly when cooked food is left out
at room temperature for more than a few hours. Most bacteria grow undetected because they do not change the color or texture of
food or produce a bad odor. Freezing and refrigeration slow or stop the growth of bacteria, but does not destroy the bacteria
completely. The microbes can reactivate when the food is taken out and thawed.

Figure : Image by NIH NIAID / CC BY 2.0

Many different kinds of bacteria can lead to food infections. One of the most common is Salmonella, which is found in the
intestines of birds, reptiles, and mammals. Salmonella can spread to humans via a variety of different animal-origin foods,
including meats, poultry, eggs, dairy products, and seafood. The disease it causes, salmonellosis, typically brings about fever,
diarrhea, and abdominal cramps within twelve to seventy-two hours after eating. Usually, the illness lasts four to seven days, and
most people recover without treatment. However, in individuals with weakened immune systems, Salmonella can invade the
bloodstream and lead to life-threatening complications, such as a high fever and severe diarrhea.[1]
The bacterium Listeria monocytogenes is found in soft cheeses, unpasteurized milk, meat, and seafood. It causes a disease called
listeriosis that can bring about fever, headache, nausea, and vomiting. Listeria monocytogenes mostly affects pregnant women,
newborns, older adults, and people with cancer and compromised immune systems.
The food infection by Escherichia coli is found in raw or undercooked meat, raw vegetables, unpasteurized milk, minimally
processed ciders and juices, and contaminated drinking water. Symptoms can occur a few days after eating, and include watery and
bloody diarrhea, severe stomach cramps, and dehydration. More severe complications may include colitis, neurological symptoms,
stroke, and hemolytic uremic syndrome. In young children, an E. coli infection can cause kidney failure and death.
The bacterium Clostridium botulinum causes botulism. Sources include improperly canned foods, lunch meats, and garlic. An
infected person may experience symptoms within four to thirty-six hours after eating. Symptoms could include nerve dysfunction,

11.3.1 [Link]
such as double vision, inability to swallow, speech difficulty, and progressive paralysis of the respiratory system. Botulism can also
be fatal.
Campylobacter jejuni causes the disease campylobacteriosis. It is the most commonly identified bacterial cause of diarrhea
worldwide. Consuming undercooked chicken, or food contaminated with the juices of raw chicken, is the most frequent source of
this infection. Other sources include raw meat and unpasteurized milk. Within two to five days after consumption, symptoms can
begin and include diarrhea, stomach cramps, fever, and bloody stools. The duration of this disease is about seven to ten days.
The food infection shigellosis is caused by Shigella, of which there are several types. Sources include undercooked liquid or moist
food that has been handled by an infected person. The onset of symptoms occurs one to seven days after eating, and can include
stomach cramps, diarrhea, fever, and vomiting. Another common symptom is blood, pus, or mucus in stool. Once a person has had
shigellosis, the individual is not likely to get infected with that specific type again for at least several years. However, they can still
become infected with other types of Shigella.
Staphylococcus aureus causes staphylococcal food poisoning. Food workers who carry this kind of bacteria and handle food
without washing their hands can cause contamination. Other sources include meat and poultry, egg products, cream-filled pastries,
tuna, potato and macaroni salad, and foods left unrefrigerated for long periods of time. Symptoms can begin thirty minutes to eight
hours after eating, and include diarrhea, vomiting, nausea, stomach pain, and cramps. This food infection usually lasts one to two
days.
Found in raw oysters and other kinds of seafood, Vibrio vulnificus belongs to the same family as the bacteria which cause cholera.
This food contaminant can result in the Vibrio infection. Symptoms can begin anywhere from six hours to a few days after
consumption, and include chills, fever, nausea, and vomiting. This disease is very dangerous and can result in fatalities, especially
in people with underlying health problems.[2]

Virus
Viruses are another type of pathogen that can lead to food infections, however they are less predominant than bacteria. Viruses
differ from bacteria in that they cannot grow and reproduce in foods. Instead, viruses that cause human diseases can only reproduce
inside human cells (Figure ). Hepatitis A is one of the more well-known food-contaminating viruses. Sources include raw
shellfish from polluted water, and food handled by an infected person. This virus can go undetected for weeks and, on average,
symptoms do not appear until about one month after exposure. At first, symptoms include malaise, loss of appetite, nausea,
vomiting, and fever. Three to ten days later, additional symptoms can manifest, including jaundice and darkened urine. Severe
cases of a hepatitis A can result in liver damage and death.
The most common form of contamination from handled foods is the norovirus, which is also known as the Norwalk-like virus, or
the calicivirus. Sources include raw shellfish from polluted water, salads, sandwiches, and other ready-to-eat foods handled by an
infected person. The norovirus causes gastroenteritis and within one to three days it leads to symptoms, such as nausea, vomiting,
diarrhea, stomach pain, headache, and a low-grade fever.[3]

11.3.2 [Link]
 Figure : Viruses in the Human Body.
Image by Allison Calabrese / CC BY 4.0

Parasitic Protozoa
Food-contaminating parasitic protozoa are microscopic organisms that may be spread in food and water. Several of these creatures
pose major problems to food production worldwide. They include Anisakis, microscopic worms that invade the stomach or the
intestines. Sources of this parasite include raw fish. This parasite can result in the Anisakis infection, with symptoms that begin
within a day or less and include abdominal pain, which can be severe.
Cryptosporidium lives in the intestines of infected animals. Another common source is drinking water, when heavy rains wash
animal wastes into reservoirs. One major problem with this pathogen is that it is extremely resistant to disinfection with chlorine.
Cryptosporidium causes the disease cryptosporidiosis, with symptoms that begin one to twelve days after exposure and include
watery stools, loss of appetite, vomiting, a low-grade fever, abdominal cramps, and diarrhea. For HIV/AIDS patients and others
with weakened immune systems, the disease can be severe, and sometimes can lead to death.
Giardia lamblia is another parasite that is found in contaminated drinking water. In addition, it lives in the intestinal tracts of
animals, and can wash into surface water and reservoirs, similar to Cryptosporidium. Giardia causes giardiasis, with symptoms that
include abdominal cramping and diarrhea within one to three days. Although most people recover within one to two weeks, the
disease can lead to a chronic condition, especially in people with compromised immune systems.
The parasite Toxoplasma gondii causes the infection toxoplasmosis, which is a leading cause of death attributed to foodborne
illness in the United States. More than sixty million Americans carry Toxoplasma gondii, but very few have symptoms. Typically,
the body’s immune system keeps the parasite from causing disease. Sources include raw or undercooked meat and unwashed fruits
and vegetables. Handling the feces of a cat with an acute infection can also lead to the disease.[4]

Mold Toxins
Mold can grow on fruits, vegetables, grains, meats, poultry, and dairy products, and typically appears as gray or green “fur.”

11.3.3 [Link]
 Figure : Moldy nectarines by Roger McLassus
1951 / CC BY-SA 3.0
Warm, humid, or damp conditions encourage mold to grow on food. Molds are microscopic fungi that live on animals and plants.
No one knows how many species of fungi exist, but estimates range from ten- to three-hundred thousand. Unlike single-celled
bacteria, molds are multicellular, and under a microscope look like slender mushrooms. They have stalks with spores that form at
the ends. The spores give molds their color and can be transported by air, water, or insects. Spores also enable mold to reproduce.
Additionally, molds have root-like threads that may grow deep into food and be difficult to see. The threads are very deep when a
food shows heavy mold growth. Foods that contain mold may also have bacteria growing alongside it.
Some molds, like the kind found in blue cheese, are desirable in foods, while other molds can be dangerous. The spores of some
molds can cause allergic reactions and respiratory problems. In the right conditions, a few molds produce mycotoxins, which are
natural, poisonous substances that can make you sick if they are consumed. Mycotoxins are contained in and around mold threads,
and in some cases, may have spread throughout the food. The Food and Agriculture Organization of the United Nations estimates
that mycotoxins affect 25 percent of the world’s food crops. They are found primarily in grains and nuts, but other sources include
apples, celery, and other produce.
The most dangerous mycotoxins are aflatoxins, which are produced by strains of fungi called Aspergillus under certain temperature
and humidity conditions. Contamination has occurred in peanuts, tree nuts, and corn. Aflatoxins can cause aflatoxicosis in humans,
livestock, and domestic animals. Symptoms include vomiting and abdominal pain. Possible complications include liver failure,
liver cancer, and even death. Many countries try to limit exposure to aflatoxins by monitoring their presence on food and feed
products.[5]

Poisonous Mushrooms
Like molds, mushrooms are fungi and the poisonous kind produces mycotoxins that can cause food intoxication. Toxic mushrooms,
also known as toadstools, can cause severe vomiting and other symptoms. However, only a few varieties are fatal. Toxic
mushrooms cannot be made safe by cooking, freezing, canning, or processing. The only way to avoid food intoxication is to refrain
from eating them. Mushroom guides can help wild gatherers distinguish between the edible and toxic kinds[6].

11.3.4 [Link]
 Figure : Amanita Muscaria by Onder Wijsgek / CC BY 3.0

Pesticides
Pesticides are important in food production to control diseases, insects, and other pests. They protect crops and ensure a large yield.
However, synthetic pesticides can leave behind residues, particularly on produce, that can be harmful to human health. Foods that
contain the highest levels of pesticide residue include conventionally-grown peaches, apples, bell peppers, celery, nectarines,
strawberries, cherries, pears, spinach, lettuce, and potatoes. Foods that contain the lowest levels of pesticide residue include
avocados, pineapples, bananas, mangoes, asparagus, cabbage, and broccoli.[7] In many cases, the amount of pesticide exposure is
too small to pose a risk. However, harmful exposures can lead to certain health problems and complications, including cancer. Also,
infants and young children are more susceptible to the hazards of pesticides than adults. In addition, using synthetic pesticides,
herbicides, and fertilizers contributes to soil and water pollution and can be hazardous to farm workers.
To protect the public and their workers, many farmers now rely on alternatives to synthetic pesticide use, including crop rotation,
natural pesticides, and planting non food crops nearby to lure pests away. Some consumers choose to reduce their exposure to
pesticides by purchasing organic produce. Organic foods are grown or produced without synthetic pesticides or fertilizer, and all
growers and processors must be certified by the US Department of Agriculture (USDA). However, conventionally-grown produce
should be fine for fruits and vegetables that appear on the low-residue list.

Pollutants
Pollutants are another kind of chemical contaminant that can make food harmful. Chemical runoff from factories can pollute food
products and drinking water. For example, dioxins are chemical compounds created in industrial processes, such as manufacturing
and bleaching pulp and paper. Fish that swim in dioxin-polluted waters can contain significant amounts of this pollutant, which
causes cancer. When metals contaminate food, it can result in serious and even life-threatening health problems. A common metal
contaminant is lead, which can be present in drinking water, soil, and air. Lead exposure most often affects children, who can suffer
from physical and mental developmental delays as a result.
Methyl mercury occurs naturally in the environment and is also produced by human activities. Fish can absorb it, and the predatory
fish that consume smaller, contaminated fish can have very high levels. This highly toxic chemical can cause mercury poisoning,
which leads to developmental problems in children, as well as autoimmune effects. A condition called Minamata disease was
identified in 1956 in Japan. It was named for the town of Minamata, which was the site of an environmental disaster when methyl
mercury was released into the surface water near a factory. Many residents experienced neurological issues, including numbness in
hands and feet, muscle weakness, a narrowing of the field of vision, damage to hearing and speech, and ataxia, which is a lack of
muscle coordination.[8]
PCBs, or polychlorinated biphenyls, are man-made organic compounds that consists of carbon, hydrogen and chlorine. Due to their
non-flammability, chemically stable, and high boiling points PCBs were manufactured and used commercially from 1929 until
1979 when it was banned. Like methylmercury, higher concentrations of this contaminant are found in predatory fish. Health
effects include complications in physical and neurological development in children, and this compound is potentially a carcinogen.
PCB contamination also can affect the immune, reproductive, nervous, and endocrine systems.[9]

11.3.5 [Link]
Learning Activities
References
1. Salmonella. (2018). Centers for Disease Control and Prevention. [Link] Updated January 24, 2018.
Accessed January 29, 2018. ↵
2. Foodborne Illnesses and Germs. (2018). Centers for Disease Control and
[Link]://[Link]/foodsafety/[Link] . Updated January 23, 2018. Accessed January 28, 2017. ↵
3. Foodborne Illnesses and Germs. (2018). Centers for Disease Control and
[Link]://[Link]/foodsafety/[Link] . Updated January 23, 2018. Accessed January 28, 2017. ↵
4. Centers for Disease Control and Prevention. (2010). “Parasites.” Last updated November 2, 2010.
[Link] ↵
5. Molds on Food: Are They Dangerous?.(2013). US Department of Agriculture, Food Safety and Inspection Service.
[Link]
handling/molds-on-food-are-they-dangerous_/ct_index. Updated August 22, 2013. Accessed January 2018. ↵
6. US Department of Agriculture, Food Safety and Inspection Service. (2010). “Molds on Food: Are They Dangerous?” Last
modified March 4, 2010. [Link]/FactSheets/Molds_On_Food/. ↵
7. Pesticide Residues in Food. (2018). World Health Organization. [Link]/mediacentre/factsheets/pesticide-residues-
food/en/. Updated January 2018. Accessed January 28, 2018. ↵
8. Minamata Disease: The History and Measures. (2002). Ministry of the Environment, Government of
[Link]://[Link]/en/chemi/hs/minamata2002/. Published 2002. Accessed December 21, 2011. ↵
9. Learn About Polychlorinated Biphenyls. (2017).US Environmental Protection Agency. [Link]
polychlorinated-biphenyls-pcbs. Updated August 10, 2017. Accessed January 28, 2018. ↵

This page titled 11.3: The Causes of Food Contamination is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated
by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
17.3: The Causes of Food Contamination by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-
SA 4.0. Original source: [Link]

11.3.6 [Link]
11.4: Protecting the Public Health
Most foodborne infections go unreported and undiagnosed. However, the CDC estimates that about seventy-six million people in
the United States become ill from foodborne pathogens or other agents every year. In North America, a number of government
agencies work to educate the public about food infections and intoxications, prevent the spread of disease, and quell any major
problems or outbreaks. They include the CDC, the FDA, and the USDA, among other organizations.

Efforts on the Governmental Level

A number of government agencies work to ensure food safety and to protect the public from foodborne illness. Food regulatory
agencies work to protect the consumer and ensure the safety of our food. Food and drug regulation in the United States began in the
late nineteenth century when state and local governments began to enact regulatory policies. In 1906, Congress passed the Pure
Food and Drugs Act, which led to the creation of the US Food and Drug Administration (FDA). Today, a number of agencies are in
charge of monitoring how food is produced, processed, and packaged.[1]
The USDA and the FDA enforce laws regarding the safety of domestic and imported food. In addition, the Federal Food, Drug, and
Cosmetic Act of 1938 gives the FDA authority over food ingredients. The FDA enforces the safety of domestic and imported foods.
It also monitors supplements, food labels, claims that corporations make about the benefits of products, and pharmaceutical drugs.
Sometimes, the FDA must recall contaminated foods and remove them from the market to protect public health. For example, in
2011 contaminated peanut butter led to the recall of thousands of jars of a few popular brands.[2] Recalls are almost always
voluntary and often are requested by companies after a problem has been discovered. In rare cases, the FDA will request a recall.
But no matter what triggers the removal of a product, the FDA’s role is to oversee the strategy and assess the adequacy and
effectiveness of the recall.
Many consumers have concerns about safety practices during the production and distribution of food. This is especially critical
given recent outbreaks of foodborne illnesses. For example, during fall 2011 in the United States, there was an eruption of the
bacteria Listeria monocytogenes in cantaloupe. It was one of the deadliest outbreaks in over a decade and resulted in a number of
deaths and hospitalizations.[3] In January 2011, the Food Safety Modernization Act was passed to grant more authority to the FDA
to improve food safety. The FDA and other agencies also address consumer-related concerns about protecting the nation’s food
supply in the event of a terrorist attack.
The USDA headed by the Secretary of Agriculture, develops and executes federal policy on farming and food. This agency
supports farmers and ranchers, protects natural resources, promotes trade, and seeks to end hunger in the United States and abroad.
The USDA also assures food safety, and in particular oversees the regulation of meat, poultry, and processed egg products. The
CDC tracks outbreaks, identifies the causes of food infection and intoxication, and recommends ways to prevent foodborne illness.
Other government agencies that play a role in protecting the public include the Food Safety and Inspection Service, a division of
the USDA, which enforces laws regulating meat and poultry safety. The Agricultural Research Service, which is the research arm
of the USDA, investigates a number of agricultural practices, including those related to animal and crop safety. The National
Institute of Food and Agriculture conducts research and education programs on food safety for farmers and consumers.
The Environmental Protection Agency (EPA) works to protect human health and the environment. Founded in 1970, the agency
conducts environmental assessment, education, research, and regulation. The EPA also works to prevent pollution and protect
natural resources. Two of its many regulatory practices in the area of agriculture include overseeing water quality and the use of
[Link] EPA approves pesticides and other chemicals used in agriculture, and sets limits on how much residue can remain on
food. The FDA analyzes food for surface residue and waxes. Processing methods can either reduce or concentrate pesticide residue
in foods. Therefore, the Food Quality Protection Act, which was passed in 1996, requires manufacturers to show that pesticide
levels are safe for children.

Efforts within the Food Industry

The Hazard Analysis Critical Control Points (HACCP) is a program within the food industry designed to promote food safety and
prevent contamination by identifying all areas in food production and retail where contamination could occur. Companies and
retailers determine the points during processing, packaging, shipping, or shelving where potential contamination may occur.. Those
companies or retailers must then establish critical control points to prevent, control, or eliminate the potential for food

11.4.1 [Link]
contamination. The USDA requires the food industry to follow HACCP for meat and poultry, while the FDA requires it for seafood,
low-acid canned-food, and juice. HACCP is voluntary for all other food products but its main goal is to prevent contamination at all
costs.

 Everyday Connection

The Seven Steps to HACCP:

1. Conduct a hazard analysis: The manufacturer must first determine any food safety hazards (ex. biological, chemicals, or
physical) and identify preventative measures to control the hazards.
2. Identify the critical control points: Critical control point (CCP) is a point or procedure in food manufacturing where control
can be applied to prevent or eliminate food hazards that may cause the food to be unsafe.
3. Establish critical limits: A critical limit is the maximum or minimum value that a food hazard must be controlled at a CCP
to prevent, eliminate or reduce it to an acceptable level.
4. Establish monitoring requirements: The manufacture must establish procedures to monitor the control points to ensure the
process is under control and not above the CCP.
5. Establish corrective actions: Corrective actions are needed when monitoring indicates a deviation from the established
critical limit to ensure that no produce injurious to health has occurred as a result of the deviation.
6. Establish verification procedures: Verification ensures that the HACCP plan is adequate with CCP records, critical limits
and microbial sampling and analysis.
7. Record keeping procedure: The manufacturer must maintain certain documents including its hazard analysis, HACCP plan,
and records monitoring the CCP, critical limits, and the verification of handling processed deviations.
For more information on the HACCP visit [Link]

Learning Activities
1. History of Food and Drug Regulation in the United States. (2010). [Link] Encyclopedia. [Link]
s=History+of+Food+and+Drug+Regulation+in+the+United+States. Published February 4, 2010. Accessed January 28, 2018. ↵
2. FDA 101: Product Recalls—From First Alert to Effectiveness Checks. (2011). US Food and Drug Administration.
[Link] Updated September 9, 2011. Accessed January 18,
2018. ↵
3. Centers for Disease Control and Prevention. (2011). “Multistate Outbreak of Listeriosis Associated with Jensen Farms
Cantaloupe—United States.” August–September, 2011. [Link]
mm6039a5_w. ↵

This page titled 11.4: Protecting the Public Health is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by
Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
17.4: Protecting the Public Health by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0.
Original source: [Link]

11.4.2 [Link]
11.5: The Food System
The food system is a network of farmers and related operations, including food processing, wholesale and distribution, retail,
industry technology, and marketing. The milk industry, for example, includes everything from the farm that raises livestock, to the
milking facility that extracts the product, to the processing company that pasteurizes milk and packages it into cartons, to the
shipping company that delivers the product to stores, to the markets and groceries that stock and sell the product, to the advertising
agency that touts the product to consumers. All of these components play a part in a very large system.

Figure : Image by Morten Just / CC BY-NC 3.0

Two important aspects of a food system are preservation and processing. Each provides for or protects consumers in different ways.
Food preservation includes the handling or treating of food to prevent or slow down spoilage. Food processing involves
transforming raw ingredients into packaged food, from fresh-baked goods to frozen dinners. Although there are numerous benefits
to both, preservation and processing also pose some concerns, in terms of both nutrition and sustainability.

This page titled 11.5: The Food System is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer
Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts
platform.
17.5: The Food System by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original
source: [Link]

11.5.1 [Link]
11.6: Food Preservation
Food preservation protects consumers from harmful or toxic food. There are different ways to preserve food. Some are ancient
methods that have been practiced for generations, such as curing, smoking, pickling, salting, fermenting, canning, and preserving
fruit in the form of jam. Others include the use of modern techniques and technology, including drying, vacuum packing,
pasteurization, and freezing and refrigeration. Preservation guards against foodborne illnesses, and also protects the flavor, color,
moisture content, or nutritive value of food.

Food Irradiation: What You Need to Know

Irradiation does not make foods radioactive, compromise nutritional quality, or noticeably change the taste, texture, or appearance
of food. In fact, any changes made by irradiation are so minimal that it is not easy to tell if a food has been irradiated.
Food irradiation (the application of ionizing radiation to food) is a technology that improves the safety and extends the shelf life of
foods by reducing or eliminating microorganisms and insects. Like pasteurizing milk and canning fruits and vegetables, irradiation
can make food safer for the consumer. The Food and Drug Administration (FDA) is responsible for regulating the sources of
radiation that are used to irradiate food. The FDA approves a source of radiation for use on foods only after it has determined that
irradiating the food is safe.

Why Irradiate Food?

Irradiation can serve many purposes.
Prevention of Foodborne Illness – to effectively eliminate organisms that cause foodborne illness, such as Salmonella and E.
coli.
Preservation – to destroy or inactivate organisms that cause spoilage and decomposition and extend the shelf life of foods.
Control of Insects – to destroy insects in or on tropical fruits imported into the United States. Irradiation also decreases the need
for other pest-control practices that may harm the fruit.
Delay of Sprouting and Ripening – to inhibit sprouting (e.g., potatoes) and delay ripening of fruit to increase longevity.
Sterilization – irradiation can be used to sterilize foods, which can then be stored for years without refrigeration. Sterilized
foods are useful in hospitals for patients with severely impaired immune systems, such as patients with AIDS or undergoing
chemotherapy. Foods that are sterilized by irradiation are exposed to substantially higher levels of treatment than those
approved for general use.

How Is Food Irradiated?

There are three sources of radiation approved for use on foods.
Gamma rays are emitted from radioactive forms of the element cobalt (Cobalt 60) or of the element cesium (Cesium 137).
Gamma radiation is used routinely to sterilize medical, dental, and household products and is also used for the radiation
treatment of cancer.
X-rays are produced by reflecting a high-energy stream of electrons off a target substance (usually one of the heavy metals) into
food. X-rays are also widely used in medicine and industry to produce images of internal structures.
Electron beam (or e-beam) is similar to X-rays and is a stream of high-energy electrons propelled from an electron accelerator
into food.

Is Irradiated Food Safe to Eat?

The FDA has evaluated the safety of irradiated food for more than 30 years and has found the process to be safe. The World Health
Organization (WHO), the Centers for Disease Control and Prevention (CDC) and the U.S. Department of Agriculture (USDA) have
also endorsed the safety of irradiated food.
The FDA has approved a variety of foods for irradiation in the United States including:
Beef and Pork
Crustaceans (e.g., lobster, shrimp, and crab)
Fresh Fruits and Vegetables

11.6.1 [Link]
 Lettuce and Spinach
Poultry
Seeds for Sprouting (e.g., for alfalfa sprouts)
Shell Eggs
Shellfish – Molluscan (e.g., oysters, clams, mussels, and scallops)
Spices and Seasonings

Figure : Image by USDA / CC BY 4.0

How Will I Know if My Food Has Been Irradiated?

The FDA requires that irradiated foods bear the international symbol for irradiation. Look for the Radura symbol along with the
statement “Treated with radiation” or “Treated by irradiation” on the food label. Bulk foods, such as fruits and vegetables, are
required to be individually labeled or to have a label next to the sale container. The FDA does not require that individual
ingredients in multi-ingredient foods (e.g., spices) be labeled. It is important to remember that irradiation is not a replacement for
proper food handling practices by producers, processors, and consumers. Irradiated foods need to be stored, handled, and cooked in
the same way as non-irradiated foods, because they could still become contaminated with disease-causing organisms after
irradiation if the rules of basic food safety are not followed.[1]

References
1. Food Irradiation. (2018). U.S. Food and Drug Administration. [Link]
Updated January 4, 2018. Accessed January 18, 2018. ↵

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11.6.2 [Link]
11.7: Food Processing
Food processing includes the methods and techniques used to transform raw ingredients into packaged food. Workers in this
industry use harvested crops or slaughtered and butchered livestock to create products that are marketed to the public. There are
different ways in which food can be processed, from a one-off product, such as a wedding cake, to a mass-produced product, such
as a line of cupcakes packaged and sold in stores.

The Pros and Cons of Food Processing

Food processing has a number of important benefits, such as creating products that have a much longer shelf life than raw foods.
Also, food processing protects the health of the consumer and allows for easier shipment and the marketing of foods by
corporations. However, there are certain drawbacks. Food processing can reduce the nutritional content of raw ingredients. For
example, canning involves the use of heat, which destroys the vitamin C in canned fruit. Also, certain food additives that are
included during processing, such as high fructose corn syrup, can affect the health of a consumer. However, the level of added
sugar can make a major difference. Small amounts of added sugar and other sweeteners, about 6 to 9 teaspoons a day or less, are
not considered harmful.[1]

Figure : Image by Dean Hochman / CC BY 2.0

Food Additives
If you examine the label for a processed food product, it is not unusual to see a long list of added materials. These natural or
synthetic substances are food additives and there are more than three hundred used during food processing today. The most popular
additives are benzoates, nitrites, sulfites, and sorbates, which prevent molds and yeast from growing on food.[2] Food additives are
introduced in the processing stage for a variety of reasons. Some control acidity and alkalinity, while others enhance the color or
flavor of food. Some additives stabilize food and keep it from breaking down, while others add body or texture. Table 17.1 lists
some common food additives and their uses:
Table 17.1 Food Additives

11.7.1 [Link]
 Additive Reason for Adding

Beta-carotene Adds artificial coloring to food

Caffeine Acts as a stimulant

Citric acid Increases tartness to prevent food from becoming rancid

Dextrin Thickens gravies, sauces, and baking mixes

Gelatin Stabilizes, thickens, or texturizes food

Modified food starch Keeps ingredients from separating and prevents lumps

MSG Enhances flavor in a variety of foods

Pectin Gives candies and jams a gel-like texture

Polysorbates Blends oil and water and keep them from separating

Soy lecithin Emulsifies and stabilizes chocolate, margarine, and other items

Sulfites Prevent discoloration in dried fruits

Xanthan gum Thickens, emulsifies, and stabilizes dairy products and dressings

Source: Chemical Cuisine: Learn about Food Additives. Center for Science in the Public
[Link]://[Link]/reports/[Link]. Published 2012. Accessed January 20, 2018.

The Pros and Cons of Food Additives

The FDA works to protect the public from potentially dangerous additives. Passed in 1958, the Food Additives Amendment states
that a manufacturer is responsible for demonstrating the safety of an additive before it can be approved. The Delaney Clause that
was added to this legislation prohibits the approval of any additive found to cause cancer in animals or humans. However, most
additives are considered to be “generally recognized as safe,” a status that is determined by the FDA and referred to as GRAS.
Food additives are typically included in the processing stage to improve the quality and consistency of a product. Many additives
also make items more “shelf stable,” meaning they will last a lot longer on store shelves and can generate more profit for store
owners. Additives can also help to prevent spoilage that results from changes in temperature, damage during distribution, and other
adverse conditions. In addition, food additives can protect consumers from exposure to rancid products and foodborne illnesses.
Food additives aren’t always beneficial, however. Some substances have been associated with certain diseases if consumed in large
amounts. For example, the FDA estimates that sulfites can cause allergic reactions in 1 percent of the general population and in 5
percent of asthmatics. Similarly, the additive monosodium glutamate, which is commonly known as MSG, may cause headaches,
nausea, weakness, difficulty breathing, rapid heartbeat, and chest pain in some individuals.[3]

References
1. Sugar and Carbohydrates. American Heart Association.
[Link]/HEARTORG/GettingHealthy/NutritionCenter/HealthyDietGoals/Sugars-and-
Carbohydrates_UCM_303296_Article.jsp#. Updated April 20, 2017. Accessed January 4, 2018. ↵
2. The Dangers of Food Additives. How Stuff Works. [Link]/wellness/food-nutrition/facts/dangers-of-food -
[Link]. Accessed October 5, 2011. ↵
3. The Issues: Additives. Sustainable Table. [Link]/issues/additives/#fn14. Accessed October 10, 2011. ↵

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11.7.2 [Link]
17.7: Food Processing by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original
source: [Link]

11.7.3 [Link]
11.8: The Effect of New Technologies
As mentioned earlier, new technology has had a tremendous effect on the food we eat and the customs and culture related to food
consumption. For example, microwaves are used to reduce cooking time or to heat up leftover food. Refrigerators and freezers
allow produce to travel great distances and last longer. On the extreme end of making food last longer, there is special food for
astronauts that is appropriate for consumption in space. It is safe to store, easy to prepare in the low-gravity environment of a
spacecraft, and contains balanced nutrition to promote the health of people working in space. In the military, soldiers consume
Meals Ready-to-Eat (MREs), which contain an entire meal in a single pouch.

Consumer Info About Food From Genetically Engineered Plants

FDA regulates the safety of food for humans and animals, including foods produced from genetically engineered (GE) plants.
Foods from GE plants must meet the same food safety requirements as foods derived from traditionally bred plants. Read more at
Consumer Info About Food From Genetically Engineered Plants.[1]

Genetically Modified Foods

Genetically modified foods (also known as GM or GMO foods), are plants or animals that have undergone some form of genetic
engineering. In the United States, much of the soybean, corn, and canola crop is genetically modified. The process involves the
alteration of an organism’s DNA, which allows farmers to cultivate plants with desirable characteristics.[2] For example, scientists
could extract a gene that produces a chemical with antifreeze properties from a fish that lives in an arctic region (such as a
flounder). They could then splice that gene into a completely different species, such as a tomato, to make it resistant to frost, which
would enable farms to grow that crop year-round.[3]
Certain modifications can be beneficial in resisting pests or pesticides, improving the ripening process, increasing the nutritional
content of food, or providing resistance to common viruses. Although genetic engineering has improved productivity for farmers, it
has also stirred up debate about consumer safety and environmental protection. Possible side effects related to the consumption of
GM foods include an increase in allergenicity, or tendencies to provoke allergic reactions. There is also some concern related to the
possible transfer of the genes used to create genetically engineered foods from plants to people. This could influence human health
if antibiotic-resistant genes are transferred to the consumer. Therefore, the World Health Organization (WHO) and other groups
have encouraged the use of genetic engineering without antibiotic-resistance genes. Genetically modified plants may adversely
affect the environment as well and could lead to the contamination of non-genetically engineered organisms.[4]
Genetically modified foods fall under the purview of the EPA, the USDA, and the FDA. Each agency has different responsibilities
and concerns in the regulation of GM crops. The EPA ensures that pesticides used for GM plants are safe for the environment. The
USDA makes sure genetically engineered seeds are safe for cultivation prior to planting. The FDA determines if foods made from
GM plants are safe to eat. Although these agencies act independently, they work closely together and many products are reviewed
by all three.[5]

References
1. Foods from Genetically Engineered Plants. U.S. Food and Drug Administration.
[Link] Updated January 4, 2018. Accessed January 20, 2018. ↵
2. What Are Genetically Modified Foods?. [Link].
[Link] Last modified November 5, 2008. Accessed October
11, 2011. ↵
3. Whitman DB. Genetically Modified Foods: Harmful or Helpful?. CSA Discovery Guides. 2000; 1-13.
[Link]/arise/resources/docs/GM%20foods%[Link]. Accessed January 20, 2018. ↵
4. Food Safety: 20 Questions on Genetically Modified Foods. World Health Organization.
[Link] Updated May 2014. Accessed January 18, 2018. ↵
5. Whitman DB. Genetically Modified Foods: Harmful or Helpful?. CSA Discovery Guides. 2000; 1-13.
[Link]/arise/resources/docs/GM%20foods%[Link]. Accessed January 20, 2018. ↵

11.8.1 [Link]
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Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
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11.8.2 [Link]
11.9: Efforts on the Consumer Level- What You Can Do
Consumers can also take steps to prevent foodborne illness and protect their health. Although you can often detect when mold is
present, you can’t see, smell, or taste bacteria or other agents of foodborne disease. Therefore, it is crucial to take measures to
protect yourself from disease. The four most important steps for handling, preparing, and serving food are[1]:
Clean. Wash hands thoroughly. Clean surfaces often and wash utensils after each use. Wash fruits and vegetables (even if you
plan to peel them).
Separate. Don’t cross-contaminate food during preparation and storage. Use separate cutting boards for produce and for meat,
poultry, seafood, and eggs. Store food products separately in the refrigerator.
Cook. Heat food to proper temperatures. Use a food thermometer to check the temperature of food while it is cooking. Keep
food hot after it has been cooked.
Chill. Refrigerate any leftovers within two hours. Never thaw or marinate food on the counter.
Know when to keep food and when to throw it out. It can be helpful to check the website [Link] which explains
how long refrigerated food remains fresh.

Buying Food
It is best to buy your food from reputable grocers with clean, sanitary facilities, that keep products at appropriate temperatures.
Consumers should examine food carefully before they purchase it. It is important to look at food in glass jars, check the stems on
fresh produce, and avoid bruised fruit. Do not buy canned goods with dents or bulges, which are at risk for contamination with
Clostridium botulinum. Fresh meat and poultry are usually free from mold, but cured and cooked meats should be examined
carefully. Also, avoid torn, crushed, or open food packages, and do not buy food with frost or ice crystals, which indicates that the
product has been stored for a long time, or thawed and refrozen. It is also a good idea to keep meat, poultry, seafood, and eggs
separate from other items in your shopping cart as you move through the grocery store.

Storing Food
Refrigerate perishable foods quickly; they should not be left out for more than two hours. The refrigerator should be kept at 40°F
(or 4°C) or colder, and checked periodically with a thermometer. Store eggs in a carton on a shelf in the refrigerator, and not on the
refrigerator door where the temperature is warmest. Wrap meat packages tightly and store them at the bottom of the refrigerator, so
juices won’t leak out onto other foods. Raw meat, poultry, and seafood should be kept in a refrigerator for only two days.
Otherwise, they should be stored in the freezer, which should be kept at 0°F (or −18°C). Store potatoes and onions in a cool, dark
place, but not under a sink because leakage from pipes could contaminate them. Empty cans of perishable foods or beverages that
have been opened into containers, and promptly place them in a refrigerator. Also, be sure to consume leftovers within three to five
days, so mold does not have a chance to grow.

Preparing Food
Wash hands thoroughly with warm, soapy water for at least twenty seconds before preparing food and every time after handling
raw foods. Washing hands is important for many reasons. One is to prevent cross-contamination between foods. Also, some
pathogens can be passed from person to person, so hand washing can help to prevent this. Fresh fruits and vegetables should also
be rinsed thoroughly under running water to clean off pesticide residue[2].
This is particularly important for produce that contains a high level of residue, such as apples, pears, spinach, and potatoes.
Washing also removes most dirt and bacteria from the surface of produce.
Other tips to keep foods safe during preparation include defrosting meat, poultry, and seafood in the refrigerator, microwave, or in a
water-tight plastic bag submerged in cold water. Never defrost at room temperature because that is an ideal temperature for bacteria
to grow. Also, marinate foods in the refrigerator and discard leftover marinade after use because it contains raw juices. Always use
clean cutting boards, which should be washed with soap and warm water by hand or in a dishwasher after each use. Another way to
sanitize cutting boards is to rinse them with a solution of 5 milliliters (1 teaspoon) chlorine bleach to about 1 liter (1 quart) of water.
If possible, use separate cutting boards for fresh produce and for raw meat. Also, wash the top before opening canned foods to
prevent dirt from coming into contact with food.

11.9.1 [Link]
Cooking Food
Cooked food is safe to eat only after it has been heated to an internal temperature that is high enough to kill bacteria. You cannot
judge the state of “cooked” by color and texture alone. Instead, use a food thermometer to be sure. The appropriate minimum
cooking temperature varies depending on the type of food:
Whole cuts of beef, veal, lamb, and pork, including fresh ham: 145°F (then allow the meat to rest for 3 minutes before carving
or eating)
Fish with fins: 145°F or cook until the flesh is opaque and separates easily with a fork
Ground meats, such as beef and pork: 160°F
All poultry, including ground chicken and turkey: 165°F
Leftovers and casseroles: 165°F
When microwaving, rotate the dish and stir contents several times to ensure even cooking.

Serving Food
After food has been cooked, the possibility of bacterial growth increases as the temperature drops. So, food should be kept above
the safe temperature of 140°F, using a heat source such as a chafing dish, warming tray, or slow cooker. Cold foods should be kept
at 40°F or lower. When serving food, keep it covered to block exposure to any mold spores hanging in the air. Use plastic wrap to
cover foods that you want to remain moist, such as fresh fruits, vegetables, and salads. After a meal, do not keep leftovers at room
temperature for more than two hours. They should be refrigerated as promptly as possible. It is also helpful to date leftovers, so
they can be used within a safe time, which is generally three to five days when stored in a refrigerator.

References
1. US Department of Health and Human Services. “Keep Food Safe.” Food [Link]. Accessed December 21, 2011.
[Link]
2. California Department of Pesticide Regulation. “Pesticides and Food: How We Test for Safety.” Pesticide Info: What You
Should Know about Pesticides, no. #E09/REV. Accessed December 21, 2011. [Link]/docs/dept/factshts/residu2.
3. [Link]

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11.9.2 [Link]
 CHAPTER OVERVIEW

12: Nutritional Issues

Learning Objectives
By the end of this chapter, you will be able to:
Describe the different types of diets
Describe the relationship between nutrition and health
Describe overnutrition, undernutrition, and malnutrition
Describe different careers in nutrition

There are a multitude of diets across the globe, in all regions and cultures. Each is influenced by the traditions of the past, along
with the produce and livestock available. Traditional diets around the globe, such as for Native Hawaiians, were comprised of foods
low in fats like fresh fish, and high in complex carbohydrates such as kalo (taro) and ‘ulu (breadfruit). However, with
modernization and the influence from other ethnic groups that have migrated to the Hawaiian Island chain, the diet has transitioned
to be high in animal fat, processed meats, and simple carbohydrates. These changes have played a role in the shift in health issues
that many Native Hawaiians are facing today. To learn more about the nutrition transition in the Pacific, visit
[Link]/ctahr/pacificfoodguide/[Link]/regional-information/.
Good nutrition equates to receiving enough (but not too much) of the macronutrients (proteins, carbohydrates, fats, and water) and
micronutrients (vitamins and minerals) so that the body can stay healthy, grow properly, and work effectively. The phrase “you are
what you eat” means that your body will respond to the food it receives, either good or bad. Processed, sugary, high-fat, and
excessively salted foods leave the body unable to perform effectively. By contrast, eating a variety of foods from all food groups
fuels the body by providing what it needs to produce energy, promote metabolic activity, prevent micronutrient deficiencies, ward
off chronic disease, and bolstering a sense of overall health and well-being.
12.1: Introduction to Nutritional Issues
12.2: Comparing Diets
12.3: Calories In Versus Calories Out
12.4: Nutrition, Health and Disease
12.5: Threats to Health
12.6: Undernutrition, Overnutrition, and Malnutrition
12.7: Food Insecurity
12.8: Careers in Nutrition

Thumbnail: “Earth in Hand” Image from [Link]

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1
12.1: Introduction to Nutritional Issues
Mai ka piko o ke poʻo a ka poli o ka wāwae, a laʻa ma na kihi ʻhā o ke kino
From the crown of the head to the soles of the feet, and the four corners of the body

Figure : “Earth in Hand” Image from [Link]

There are a multitude of diets across the globe, in all regions and cultures. Each is influenced by the traditions of the past, along
with the produce and livestock available. Traditional diets around the globe, such as for Native Hawaiians, were comprised of foods
low in fats like fresh fish, and high in complex carbohydrates such as kalo (taro) and ‘ulu (breadfruit). However, with
modernization and the influence from other ethnic groups that have migrated to the Hawaiian Island chain, the diet has transitioned
to be high in animal fat, processed meats, and simple carbohydrates. These changes have played a role in the shift in health issues
that many Native Hawaiians are facing today. To learn more about the nutrition transition in the Pacific, visit
[Link]/ctahr/pacificfoodguide/[Link]/regional-information/.
Good nutrition equates to receiving enough (but not too much) of the macronutrients (proteins, carbohydrates, fats, and water) and
micronutrients (vitamins and minerals) so that the body can stay healthy, grow properly, and work effectively. The phrase “you are
what you eat” means that your body will respond to the food it receives, either good or bad. Processed, sugary, high-fat, and
excessively salted foods leave the body unable to perform effectively. By contrast, eating a variety of foods from all food groups
fuels the body by providing what it needs to produce energy, promote metabolic activity, prevent micronutrient deficiencies, ward
off chronic disease, and bolstering a sense of overall health and well-being.

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12.1.1 [Link]
12.2: Comparing Diets
Diet Trends and Health
In the past, health was regarded merely as the absence of illness. However, a growing understanding of the complexity and
potential of the human condition has prompted a new way of thinking about health. Today, we focus on the idea of wellness, which
involves a great deal more than just not being sick. Wellness is a state of optimal well-being that enables an individual to maximize
their potential. This concept includes a host of dimensions—physical, mental, emotional, social, environmental, and spiritual—
which affect one’s quality of life.[1] Striving for wellness begins with an examination of dietary choices.

Dietary Food Trends

Hundreds of years ago, when food was less accessible and daily life required much more physical activity, people worried less
about obesity and more about simply getting enough to eat. In today’s industrialized nations, conveniences have solved some
problems and introduced new ones, including the hand-in-hand obesity and diabetes epidemics. Fad diets gained popularity as more
North Americans struggled with excess pounds. However, new evidence-based approaches that emphasize more holistic measures
are on the rise. These new dietary trends encourage those seeking to lose weight to eat healthy, whole foods first, while adopting a
more active lifestyle. These sound practices put dietary choices in the context of wellness and a healthier approach to life.

 Everyday Connections

In the past, people’s culture and location determined the foods they ate and the manner in which they prepared their meals. For
example, in Hawai‘i, taro was a staple complex carbohydrate that could be eaten in various ways such as poi and pa‘ia‘i.
Today, most people have access to a wide variety of food and can prepare them any way they choose. However, customs and
traditions still strongly influence diet and cuisine in most areas of the world. To learn more about the food and culture in the
pacific, visit [Link]/ctahr/pacificfoodguide/[Link]/regional-information/

Functional Foods
Many people seek out foods that provide the greatest health benefits. This trend is giving rise to the idea of functional foods, which
not only help meet basic nutritional needs but also are reported to fight illness and aging. According to the Academy of Nutrition
and Dietetics (AND), formerly known as the The American Dietetic Association, functional foods may reduce the risk of disease or
promote optimal health. The AND recognizes four types of functional foods. They are: conventional foods, modified foods,
medical foods, and special dietary use foods.[2]
The first group, conventional foods, represents the simplest form of functional foods. They are whole foods that have not been
modified. Examples include whole fruits and vegetables (which are abundant in phytochemicals and antioxidants), yogurt and kefir
(which contain natural probiotic bacteria that can help maintain digestive system health), and moderate amounts of dark chocolate,
made with 70% or more cacao (which contains antioxidants).
Modified foods have been fortified, enriched, or enhanced with additional nutrients or bioactive compounds. Foods are modified
using biotechnology to improve their nutritional value and health attributes. Examples of modified foods include calcium-fortified
orange juice, breads enriched with B vitamins, iodized salt, cereals fortified with vitamins and minerals, margarine enhanced with
plant sterols, and energy drinks that have been enriched with herbs (ginseng or guarana) or amino acids (taurine). It is important to
consider that the health claims of some modified foods may be debatable, or entirely fraudulent. Check with a health professional
regarding the effects of modified foods on your health.
Medical foods are designed for enteric administration under the guidance of a medical professional. (During enteric administration,
food is treated so that it goes through the stomach undigested. Instead, the food is broken down in the intestines only.) Medical
foods are created to meet very specific nutritional requirements. Examples of medical foods include liquid formulas for people with
kidney disease, liver disease, diabetes, or other health issues. Medical food is also given to comatose patients through a gastronomy
tube because they cannot eat by mouth.
Special dietary use foods do not have to be administered under a doctor’s care and can be found in a variety of stores. Similar to
medical foods, they address special dietary needs and meet the nutritional requirements of certain health conditions. For example, a

12.2.1 [Link]
bottled oral supplement administered under medical supervision is a medical food, but it becomes a special dietary use food when it
is sold to retail customers. Examples of special dietary use foods include gluten-free foods, lactose-free dairy products, and
formulas and shakes that promote weight loss.

Popular Diets
The concept of functional foods represents initiatives aimed at addressing health problems. Certain diet plans take this concept one
step further, by striving to prevent or treat specific conditions. For example, it is widely understood that people with diabetes need
to follow a particular diet. Although some of these diet plans may be nutritionally sound, use caution because some diets may be
fads or be so extreme that they actually cause health problems.
Before experimenting with a diet, discuss your plans with your doctor or a registered dietitian. Throughout this section, we will
discuss some of the more popular diets. Some fall under the category of fad diets, while others are backed by scientific evidence.
Those that fall into the latter category provide a good foundation to build a solid regimen for optimal health.

The DASH Diet

The Dietary Approaches to Stop Hypertension, or DASH diet, focuses on reducing sodium intake to either 2,300 milligrams per
day (as recommended by the Dietary Guidelines for Americans) or 1,500 milligrams per day for certain populations. The DASH
diet is an evidence-based eating plan that can help reduce high blood pressure. This plan may also decrease the risk of heart attack,
stroke, diabetes, osteoporosis, and certain cancers.[3]
DASH tips to lower sodium include:
Using spices instead of salt to add flavor
Reading sodium content on processed or canned food labels, and choosing low-sodium options
Removing some sodium from canned foods (such as beans) by rinsing the product before consumption
Avoiding salt when cooking
DASH dieters are recommended to consume a variety of whole grains and high-fiber fruits and vegetables, and moderate amounts
of low-fat dairy products, lean meats, and heart-healthy fish. In addition, DASH limits the use of saturated fats to less than 7
percent of total calories, and limits the consumption of sweets and alcohol. The DASH diet also calls for consuming less added
sugar and drinking fewer sugar-sweetened drinks. It replaces red meat with fish and legumes and calls for increased calcium,
magnesium, potassium, and fiber. Also, even though some people on the DASH diet may find it lowers their HDL (good)
cholesterol along with their LDL (bad) cholesterol, it still has a positive cumulative effect on heart health.[4]

The Gluten-Free Diet

The gluten-free diet helps people whose bodies cannot tolerate gluten, a protein found in wheat, barley, and rye. One of the most
important ways to treat this condition is to avoid the problematic foods, which is not easy. Although following a gluten-free diet is
challenging, it is prescribed for patients with gluten intolerance and celiac disease, an autoimmune disorder with a genetic link.
People who have celiac disease cannot consume gluten products without damaging their intestinal lining. Eating a gluten-free diet
means finding replacements for bread, cereal, pasta, and more. It also means emphasizing fresh fruits, vegetables, and other foods
without gluten. However, it is important to note that the gluten-free trend has become something of a fad even for those without a
gluten intolerance. Celiac disease is a relatively rare condition found in only 1 percent of the population. Therefore, a gluten-free
diet should be followed only with a physician’s recommendation.

Low-Carb Diets
Low-carb diets, which include the Atkins Diet and the South Beach Diet, focus on limiting carbohydrates—such as grains, fruit,
and starchy vegetables—to promote weight loss. Other low-carb diets include the Paleolithic (Paleo) and Ketogenic (Keto) Diet.
The Paleo diet mimics foods that humans consumed during the Stone Age or the Paleolithic period. This diet promotes higher
amounts of grass-fed only animal protein, healthy fats, and non-starchy vegetables (i.e. okra, bok choy, carrots).[5] Similarly, the
Keto diet highlights high protein intake and healthy fats however there is more flexibility with the source of animal protein and it
does not have to be limited to grass-fed.[6] Furthermore, the Paleo diet does not allow for dairy foods while the Keto diet allows
dairy foods without added sugar.

12.2.2 [Link]
The theory behind the low-carb diet is that insulin prevents the breakdown of fat by allowing sugar in the form of blood glucose to
be used for energy. Proponents of this approach believe that because limiting carbohydrates generally lowers insulin levels, it
would then cause the body to burn stored fat instead. They believe this method not only brings about weight loss, but also reduces
the risk factors for a number of conditions. However, some studies have shown that people who followed certain low-carb diet
plans for two years lost an average of nearly 9 pounds, which is similar to the amount of weight lost on higher carbohydrate diets.
[7]

The benefits of this kind of diet include an emphasis on whole, unprocessed foods and a de-emphasis of refined carbohydrates,
such as white flour, white bread, and white sugar. However, there are a number of downsides. Typically, the first two weeks allow
for only 20 grams of carbs per day, which can be dangerously low. In addition, dieters using the low-carb approach tend to
consume twice as many saturated fats as people on a diet high in healthy carbohydrates. Low-carb diets are also associated with a
higher energy intake, and the notion that “calories don’t count,” which is prevalent in this kind of diet, is not supported by scientific
evidence.[8]

The Macrobiotic Diet

The macrobiotic diet is part of a health and wellness regimen based in Eastern philosophy. It combines certain tenets of Zen
Buddhism with a vegetarian diet and supports a balance of the oppositional forces of yin and yang. Foods are paired based on their
so-called yin or yang characteristics. Yin foods are thought to be sweet, cold, and passive, while yang foods are considered to be
salty, hot, and aggressive.
Whole grains make up about 50 percent of the calories consumed and are believed to have the best balance of yin and yang. Raw
and cooked vegetables comprise about 30 percent of the diet and include kale, cabbage, collards, bok choy, and broccoli on a daily
basis, along with mushrooms and celery a few times a week. Bean or vegetable-based soups and broths can make up 5 to 10
percent of daily caloric intake. Additionally, the diet allows small amounts of fish and seafood several times a week, along with a
few servings of nuts. The macrobiotic diet prohibits certain foods, such as chocolate, tropical fruits, and animal products, because
they are believed to fall on the far end of the yin-yang spectrum, which would make it difficult to achieve a Zen-like balance.
The macrobiotic diet focuses on foods that are low in saturated fats and high in fiber, which can help to lower the risk of
cardiovascular disease. Proponents of this diet also believe that it may protect against cancer. However, many nutritionists and
healthcare providers express concerns, particularly if the diet is followed strictly. Extreme macrobiotic eating can be low in protein,
low in calories, and pose a risk for starvation. In addition, the diet is also very low in essential vitamins and minerals.[9]

The Mediterranean Diet

The traditional Mediterranean diet incorporates many elements of the dietary choices of people living in Greece and southern Italy.
The Mediterranean diet focuses on small portions of nutritionally-sound food. This diet features food from plant sources, including
vegetables, fruits, whole grains, beans, nuts, seeds, breads and potatoes, and olive oil. It also limits the consumption of processed
foods and recommends eating locally grown foods rich in micronutrients and antioxidants. Other aspects of this eating plan include
consuming fish and poultry at least twice per week, eating red meat only a few times per month, having up to seven eggs per week,
and drinking red wine in moderation. Unlike most diets, the Mediterranean diet does not cut fat consumption across the board.
Instead, it incorporates low-fat cheese and dairy products, and it substitutes olive oil, canola oil, and other healthy oils for butter
and margarine.
More than fifty years of nutritional and epidemiological research has shown that people who follow the Mediterranean diet have
some of the lowest rates of chronic disease and the highest rates of longevity among the populations of the world. Studies have
shown that the Mediterranean diet also helps to decrease excess body weight, blood pressure, blood fats, and blood sugar and
insulin levels significantly.[10]

 Tools for Change

For six years, researchers from the University of Bordeaux in France followed the dietary habits of more than seven thousand
individuals age sixty-five and over. Participants who described greater consumption of extra-virgin olive oil reportedly lowered
their risk of suffering a stroke by 41 percent. The study controlled for stroke risk factors, such as smoking, alcohol intake, high
blood pressure, and a sedentary lifestyle. To increase the amount of olive oil in your diet, try spreading olive oil instead of

12.2.3 [Link]
 butter on your toast, making your own salad dressing using olive oil, vinegar or lemon juice, and herbs, cooking with olive oil
exclusively, or simply adding a dose of it to your favorite meal.[11]

The Raw Food Diet

The raw food diet is followed by those who avoid cooking as much as possible in order to take advantage of the full nutrient
content of foods. The principle behind raw foodism is that plant foods in their natural state are the most wholesome for the body.
The raw food diet is not a weight-loss plan, it is a lifestyle choice. People who practice raw foodism eat only uncooked and
unprocessed foods, emphasizing whole fruits and vegetables. Staples of the raw food diet include whole grains, beans, dried fruits,
seeds and nuts, seaweed, sprouts, and unprocessed produce. As a result, food preparation mostly involves peeling, chopping,
blending, straining, and dehydrating fruits and vegetables.
The positive aspects of this eating method include consuming foods that are high in fiber and nutrients, and low in calories and
saturated fat. However, the raw food diet offers little in the way of protein, dairy, or fats, which can cause deficiencies of the
vitamins A, D, E, and K. In addition, not all foods are healthier uncooked, such as spinach and tomatoes. Also, cooking eliminates
potentially harmful microorganisms that can cause foodborne illnesses. Therefore, people who primarily eat raw foods should
thoroughly clean all fruit and vegetables before eating them. Poultry and other meats should always be cooked before eating.[12]

Vegetarian and Vegan Diets

Vegetarian and vegan diets have been followed for thousands of years for different reasons, including as part of a spiritual practice,
to show respect for living things, for health reasons, or because of environmental concerns. For many people, being a vegetarian is
a logical outgrowth of “thinking green.” A meat-based food system requires more energy, land, and water resources than a plant-
based food system. This may suggest that the plant-based diet is more sustainable than the average meat-based diet in the [Link]
avoiding animal flesh, vegetarians hope to look after their own health and that of the planet at the same time. Broadly speaking,
vegetarians eat beans, grains, and fruits and vegetables, and do not eat red meat, poultry, seafood, or any other animal flesh. Some
vegetarians, known as lacto vegetarians, will eat dairy products. Others, known as lacto-ovo vegetarians, will eat dairy products
and eggs. A vegan diet is the most restrictive vegetarian diet—vegans do not eat dairy, eggs, or other animal products, and some do
not eat honey.
Vegetarian diets have a number of benefits. Well-balanced eating plans can lower the risk of a number of chronic conditions,
including heart disease, diabetes, and obesity. They also help to promote sustainable agriculture. However, if a vegetarian does not
vary his or her food choices, the diet may be insufficient in calcium, iron, omega-3 fatty acids, zinc, and vitamin B12. Also, if
people who follow these diets do not plan out their meals, they may gravitate toward foods high in fats.
Table : The Pros and Cons of Seven Popular Diets

12.2.4 [Link]
 Diet Pros Cons

Recommended by the National Heart,

Lung, and Blood Institute, the
American Heart Association, and many
physicians There are very few negative factors
DASH Diet Helps to lower blood pressure and associated with the DASH diet
cholesterol Risk for hyponatremia
Reduces risk of heart disease and stroke
Reduces risk of certain cancers
Reduces diabetes risk

Reduces the symptoms of gluten

intolerance, such as chronic diarrhea,
Risk of folate, iron, thiamin, riboflavin,
cramping, constipation, and bloating
niacin, and vitamin B6 deficiencies
Promotes healing of the small intestines
Special gluten-free products can be hard
for people with celiac disease,
Gluten-Free Diet to find and expensive
preventing malnutrition
Requires constant vigilance and careful
May be beneficial for other
food label reading, since gluten is found
autoimmune diseases, such as
in many products
Parkinson’s disease, rheumatoid
arthritis, and multiple sclerosis

Not entirely evidence-based

Restricts refined carbohydrates, such as Results in higher fat and protein
white flour and white sugar consumption
Low-Carb Diet
May temporarily improve blood sugar Does not meet the RDA for
or blood cholesterol levels carbohydrates to provide glucose to the
brain

Low in saturated fats and high in fiber Not entirely evidence-based

Emphasizes whole foods and de- Lacks certain vitamins and minerals;
emphasizes processed foods supplements are often required
Macrobiotic Diet
Rich in phytoestrogens, which may Can result in a very low caloric intake
reduce the risk of estrogen-related Lack of energy may result from
cancers inadequate protein

A reduced risk of cardiovascular

disease and mortality
A lower risk of cancer
Does not specify daily serving amounts
De-emphasizes processed foods and
Potential for high fat and high calorie
emphasizes whole foods and healthy
intake as nuts and oils are calorie-dense
fats
Mediterranean Diet foods
Lower sodium intake, due to fewer
Drinking one to two glasses of wine per
processed foods
day may not be healthy for those with
Emphasis on monosaturated fats leads
certain conditions
to lower cholesterol
Highlighting fruits and vegetables
raises consumption of antioxidants

Raw Food Diet Emphasizes whole foods Not entirely evidence-based

Focuses on nutritionally-rich foods Very restrictive and limits protein and
healthy fat intake
Could encourage the development of
foodborne illness

12.2.5 [Link]
 Diet Pros Cons
Extremely difficult to follow
High in fiber which can cause essential
nutrient deficiencies

Guidelines regarding fat and nutrient

consumption must be followed
Higher risk for nutrient deficiencies
May reduce some chronic diseases such such as protein, iron, zinc, omega-3,
as cancer, heart disease, and Type 2 vitamin B12
Vegetarianism and Veganism diabetes Consumption of a high fiber diet
May help with weight reduction and interferes with mineral and nutrient
weight maintenance bioavailability
Vegetarian and vegan protein sources
are lower quality with majority missing
at least one essential amino acids

References
1. Understanding Wellness. University of Illinois at Urbana-Champaign, McKinley Health Center. 2011 The Board of Trustees of
the University of Illinois at Urbana-Champaign. [Link] Accessed April 15,
2018. ↵
2. Functional Foods. The Academy of Nutrition and Dietetics. [Link]
foods. Published July 5, 2018. Accessed April 15, 2018. ↵
3. DASH Diet Eating Plan. DASH Diet Oregon. [Link] Accessed April 12, 2018. ↵
4. DASH Diet Eating Plan. DASH Diet Oregon. [Link]/. Accessed April 12, 2018. ↵
5. Paleolithic Nutrition — A Consideration of Its Nature and Current Implications | NEJM. www-nejm-
[Link]/doi/full/10.1056/NEJM198501313120505?url_ver=Z39.88-
2003&rfr_id=ori%3Arid%[Link]&rfr_dat=cr_pub%3Dpubmed. Accessed January 21, 2020. ↵
6. Ludwig DS. (2019). The Ketogenic Diet: Evidence for Optimism but High-Quality Research Needed. Journal of
Nutrition,nxz308. doi:10.1093/jn/nxz308↵
7. Low-Carb Diet: Can It Help You Lose Weight?.The Mayo Clinic. [Link]
Accessed March 6, 2018. ↵
8. Steele V. Health and Nutritional Effects of Popular Diets. Kellogg Nutrition Symposium, The Team of Registered Dietitians &
Nutrition Professionals at Kellogg Canada Inc. Insert to Canadian Journal of Dietetic Practice and Research 64, no. 3. ↵
9. Zelman, KM. Macrobiotic Diet. [Link] Updated February 9, 2018. Accessed
April 12, 2018. ↵
10. Robinson, K. The Mediterranean Diet. [Link] Published February 6,
2018. Accessed April 15, 2018. ↵
11. More Olive Oil in Diet Could Cut Stroke Risk: Study. [Link]. [Link]
articlekey=145823. Published 2011. Accessed April 15,2018. ↵
12. Raw Food Diet. [Link]://[Link]/diet/a-z/raw-foods-diet. Published November 21, 2016. Accessed April
15, 2018. ↵

This page titled 12.2: Comparing Diets is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer
Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts
platform.
18.2: Comparing Diets by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original
source: [Link]

12.2.6 [Link]
12.3: Calories In Versus Calories Out
The ability to estimate energy expenditure and quantify calories consumed, has led to the simple conclusion that tracking or
counting “calories in” compared to “calories out” will result in an easy way to manage body weight. This logic does not take into
account the complexity and individuality of the human body. Human bodies are not static, meaning there are fluctuations from day
to day in energy needs related to set point, sleep patterns, stress levels, activity levels, and eating patterns. Something as simple as
the timing and macronutrient composition of meals, will impact the thermic effect of food, resulting in a change in energy
expenditure.

Figure : Image by mojzagrebinfo / Pixabay License

Dieting Basics/ Dieting 101

The diet and weight loss industry is big business. In 2017, The U.S. Weight Loss and Diet Control Market reported a record $72
billion dollar value to the weight loss market.[1] This dollar amount is expected to continue to rise. At the same time, there is
evidence that diets do not lead to long term weight loss for the majority of people. In observational studies, dieting was the best
predictor of future weight gain and onset of obesity.[2][3][4] Meta-analysis and reviews of randomized clinical trials reported that on
average, obesity treatments cause weight gain.[5][6] This additional weight gain leads to an increase in the set point, making it more
difficult for an individual to lose weight in the future. Others reported a 3-5 % weight loss was possible 4 years later if participants
continued all aspects of treatment.[7] For a 200 pound person, this represents a 6-10 pound weight loss. The health benefits of this
modest weight loss are unclear and it is far less what is expected or desired when following a diet. In conclusion, the diet industry
makes money from a product that is proven not to work.

Dieting and Health

The scientific evidence shows that diets lead to modest weight loss for some and future weight gain for the majority of people. This
often leads to a behavior called weight cycling or yo-yo dieting. The person continues to seek weight loss and a new diet, hoping to
get a new result. This repetition of starting and stopping diets leads to losing and gaining a similar amount of weight over and over
again. The weight goes up and down like a yo-yo. In addition, when someone cuts out food groups and restricts certain foods from
their diet, the interest in the food increases. This in combination with intense hunger resulting from energy restriction, leads to a
feeling of being out of control around foods and binge eating. To compensate for the feeling out of control, the person then restricts
the food again and is then in a restriction/ binge or overeating cycle.

12.3.1 [Link]
 Figure : Image by Kellie Taguchi / CC BY 4.0
The majority (up to 95%) of people regain the weight within three years and often gain back more.[8][9] Weight cycling puts stress
on the body causing physical complications that are harmful, resulting in lowered or slowed metabolism, a reduction in lean body
mass or muscle tissue, lowered body temperature, and increased risk for eating disorders.[10][11] Dieting and weight cycling also
have a negative impact on mental health including lower self-esteem, and increases in depression, anxiety, irritability, and
nervousness.[12] The evidence shows that dieting reduces both physical and emotional health.

Health and Body Weight

The assumption that health is determined by body weight, or a number on the scale, is outdated and not supported by science. As
obesity rates continue to rise, it has been speculated that a higher BMI stands alone as a health risk. However, there is substantial
scientific evidence to support the notion that obesity in itself does not put an individual at increased risk of disease. The majority of
epidemiological studies demonstrate that five pounds “underweight” is more harmful than 75 pounds “overweight”. [13][14][15][16]
[17]
The results of multiple studies have indicated that using weight as a criterion for health is off-target and potentially harmful.[18]
[19][20]
This suggests that it is not possible to tell how healthy an individual is simply by looking at them or calculating their BMI.

Figure : Image by 272447 / Pixabay

License
The following are measurable risk factors and markers of health that are not connected to body weight. These are good targets for
nutrition education and counseling and ways to monitor improvements of health status over time.

12.3.2 [Link]
 Biomarkers: blood pressure, blood glucose, total cholesterol, high-density lipoproteins, low-density lipoproteins, triglycerides
Regular movement/ activity/ exercise
Stress and inflammation
Hormone balance
Mental health status
Sleep
Quality of life
Connection to the community
Spiritual health
Intellectual health
Occupational health

Health at Every Size

At its foundation, Health at Every Size (HAES) supports behavior changes that create sustainable habits to improve health and
promote a better quality of life.[21] The HAES approach is an alternative to the weight/size-based approach with a focus on
improving health without a focus on weight loss. The research shows this model is able to promote sustainable improvements in
health.
“In a study comparing the HAES model to a diet approach, though only dieters lost weight, both groups initially had similar
improvements in metabolic fitness, activity levels, psychological measures, and eating behaviors. After two years, dieters had
regained their weight and lost the health improvements, while the HAES group sustained their health improvements”.[22]

The Health At Every Size® Principles are:

1. Weight Inclusivity: Accepting and respecting the diversity of body shapes and sizes
2. Health Enhancement: Recognizing that health and well-being are multi-dimensional and that they include physical, social,
spiritual, occupational, emotional, and intellectual aspects
3. Respectful Care: Promoting all aspects of health and well-being for people of all sizes
4. Eating for Well-being: Promoting eating in a manner which balances individualized nutritional needs, hunger, satiety, appetite,
and pleasure
5. Life-Enhancing Movement: Promoting individually appropriate, enjoyable, life-enhancing physical activity, rather than
exercise that is focused on a goal of weight loss
In the Hawaiian language, Lokahi means “unity, agreement, accord, and harmony”.[23] The concept of Lokahi can be used to
describe the balance between the relationship an individual has with the body, the mind, the spirit, and the rest of the world.
The image below illustrates the overlap of the Hawaiian principle of Lokahi with the Health at Every Size principle #2: Health
enhancement.

12.3.3 [Link]
 Figure : Image by Jennifer Draper / CC BY 4.0

Intuitive Eating
Intuitive eating is a non-diet approach to eating that promotes a connection to body cues of hunger and fullness and the selection of
foods based on both pleasure and nutrient density.[24] When an individual is able to disconnect from diet culture and a focus on
weight loss, they are able to eat in ways that support having energy throughout the day and feel competent around all foods. Instead
of an outward focus on counting calories, dietary restriction, and measuring food portions, intuitive eating teaches a mindfulness
practice of going inward and learning to respond to the cues and rhythms of the body. A review of 22 intervention studies that
compared traditional weight loss to the intuitive eating approach concluded that the participants in the non-diet groups were able to
stop unhealthy weight controlling behaviors, improve metabolic fitness and reduce risk factors, increase body satisfaction, and
improve psychological distress.[25] While the non-diet approach has not been shown to promote weight loss, a review of clinical
trials concluded that intuitive eating was able to stabilize weight and help to prevent future weight gain, in addition to an
improvement in blood pressure and cholesterol levels, and dietary intake.[26]

Figure : Image by CDC / Unsplash License

The 10 Principles of Intuitive Eating

1. Reject the diet mentality
2. Honor your hunger
3. Make peace with food
4. Challenge the food police
5. Discover the satisfaction factor

12.3.4 [Link]
 6. Feel your fullness
7. Cope with your emotions with kindness
8. Respect your body
9. Movement- Feel the difference
10. Honor your health – gentle nutrition

References
1. The U.S. weight loss & diet control market. (2019). Marketdata LLC.
[Link]
2. Neumark-Sztainer, D., Wall, M., Story, M., & Standish, A. R. (2012). Dieting and unhealthy weight control behaviors during
adolescence: Associations with 10-year changes in body mass index. The Journal of Adolescent Health, 50(1), 80–86. ↵
3. Neumark-Sztainer, D., Wall, M., Guo, J., Story, M., Haines, J., & Eisenberg, M. (2006). Obesity, disordered eating, and eating
disorders in a longitudinal study of adolescents: How do dieters fare 5 years later? Journal of the American Dietetic
Association, 106(4), 559–568. ↵
4. Stice, E., Cameron, R. P., Killen, J. D., Hayward, C., & Taylor, C. B. (1999). Naturalistic weight-reduction efforts prospectively
predict growth in relative weight and onset of obesity among female adolescents. Journal of Consulting and Clinical
Psychology, 67(6), 967–974. ↵
5. Mann, T., Tomiyama, A. J., Westling, E., Lew, A.-M., Samuels, B., & Chatman, J. (2007). Medicare’s search for effective
obesity treatments: Diets are not the answer. The American Psychologist, 62(3), 220–233. ↵
6. Ayyad, C., & Andersen, T. (2000). Long-term efficacy of dietary treatment of obesity: A systematic review of studies published
between 1931 and 1999. Obesity Reviews, 1(2), 113–119. ↵
7. Franz, M. J., VanWormer, J. J., Crain, A. L., Boucher, J. L., Histon, T., Caplan, W., Bowman, J. D., & Pronk, N. P. (2007).
Weight-loss outcomes: A systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up.
Journal of the American Dietetic Association, 107(10), 1755–1767. ↵
8. Mann, T., Tomiyama, A. J., Westling, E., Lew, A.-M., Samuels, B., & Chatman, J. (2007). Medicare’s search for effective
obesity treatments: Diets are not the answer. The American Psychologist, 62(3), 220–233. ↵
9. Wooley, S. C., & Garner, D. M. (1994). Dietary treatments for obesity are ineffective. BMJ, 309(6955), 655–656. ↵
10. Bacon, L. (2010). Health at every size: The surprising truth about your weight. BenBella Books, Incorporated. ↵
11. Karelis, A. D., Messier, V., Brochu, M., & Rabasa-Lhoret, R. (2008). Metabolically healthy but obese women: Effect of an
energy-restricted diet. Diabetologia, 51(9), 1752–1754. ↵
12. French, S. A., & Jeffery, R. W. (1994). Consequences of dieting to lose weight: Effects on physical and mental health. Health
Psychology, 13(3), 195–212. ↵
13. Flegal, K. M., Graubard, B. I., Williamson, D. F., & Gail, M. H. (2005). Excess deaths associated with underweight,
overweight, and obesity. JAMA, 293(15), 1861–1867. ↵
14. Flegal K.M., Graubard B.I., Williamson D. F., & Gail M. H. (2018, March). Excess deaths associated with underweight,
overweight, and obesity: An evaluation of potential bias. Vital & Health Statistics. 42, 1-21 ↵
15. Orpan H. M., Berthaelot J. M., Kaplan M. S. , Feeny D. H., McFarland B., & Ross N. A. (2010). BMI and mortality: Results
from a longitudinal study of Canadian adults. Obesity (Silver Springs). 18(1), 214-8. ↵
16. Tamakoshi A., Hiroshi Y., Lin Y., Tamakoshi K., Kondo T., Suzuki S., Yagyu K., Kikuchi S., & the JACC Study Group (2010).
BMI and all-cause mortality among Japanese older adults: Findings from the Japan collaborative cohort study. Obesity. 18(2),
362-9. ↵
17. Campos P. (2004). The Obesity Myth. Gotham Books. ↵
18. Kang X., Shaw L. J., Hayes S. W., Hachamovitch R., Abidov A., Cohen I., Friedman J. D., Thomson L. E., Polk D., Germano
G., & Berman D. S. (2006). Impact of body mass index on cardiac mortality in patients with known or suspected coronary
artery disease undergoing myocardial perfusion single-photon emission computed tomography. Journal of the American
College of Cardiology. 47(7), 1418-26 ↵
19. Oreopoulos A., Padwal R., Kalantar-Zadeh K., Fonarow G. C., Norris C. M., & McAlister F. A. (2008). Body mass index and
mortality in heart failure: A meta-analysis. American Heart Journal. 156(1), 13-22. ↵
20. Olsen T. S., Dehlendorft C., Petersen H. G., & Andersen K. K. (2008). Body mass index and prestroke mortality.
Neuroepidemiology. 30, 93-100. ↵

12.3.5 [Link]
21. Association for Size Diversity and Health. (2020). HAES Principles. [Link]
22. Bacon L., Stern J. S., Van Loan M. D., & Keim N. L. (2005). Size acceptance and intuitive eating improve health for obese
female chronic dieters. Journal of the American Dietetic Association. 105(6), 929-36. ↵
23. Ulukau Hawaiian Electronic Library. [Link]/↵
24. The Original Intuitive Eating Pros. (2007 - 2019). 10 Principles of Intuitive Eating. [Link]
principles-of-intuitive-eating/↵
25. Schaefer J. T., Magnuson A. B. (2014). A review of interventions that promote eating my internal cues. Journal of the Academy
of Nutrition and Dietetics. 114(5), 734-760. ↵
26. Van Dyke N., Drinkwater E. J. (2014). Relationships between intuitive eating and health indicators: Literature review. Public
Health Nutrition. 17(8), 1757-1766. ↵

This page titled 12.3: Calories In Versus Calories Out is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by
Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
18.3: Calories In Versus Calories Out by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA
4.0. Original source: [Link]

12.3.6 [Link]
12.4: Nutrition, Health and Disease
Disorders That Can Compromise Health
When nutrients and energy are in short supply, cells, tissues, organs, and organ systems do not function properly. Unbalanced diets
can cause diseases and, conversely, certain illnesses and diseases can cause an inadequate intake and absorption of nutrients,
simulating the health consequences of an unbalanced diet. Overeating high-fat foods and nutrient-poor foods can lead to obesity
and exacerbate the symptoms of gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS). Many diseases and
illnesses, such as celiac disease, interfere with the body getting its nutritional requirements. A host of other conditions and illnesses,
such as food allergies, cancer, stomach ulcers, Crohn’s disease, and kidney and liver disease, also can impair the process of
digestion and/or negatively affect nutrient balance and decrease overall health. Some illnesses that can compromise health are
chronic and persist for a long time, some are communicable and can be transmitted between people, and some are non-
communicable and are not infectious.

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a persistent form of acid reflux that occurs more than two times per week. Acid reflux
occurs when the acidic contents of the stomach leak backward into the esophagus and cause irritation. It is estimated that GERD
affects 25 to 35 percent of the US population. An analysis of several studies published in the August 2005 issue of Annals of
Internal Medicine concludes that GERD is much more prevalent in people who are obese.[1] The most common GERD symptom is
heartburn, but people with GERD may also experience regurgitation (flow of the stomach’s acidic contents into the mouth),
frequent coughing, and trouble swallowing.
There are other causative factors of GERD that may be separate from or intertwined with obesity. The sphincter that separates the
stomach’s internal contents from the esophagus often does not function properly and acidic gastric contents seep upward.
Sometimes the peristaltic contractions of the esophagus are also sluggish and compromise the clearance of acidic contents. In
addition to having an unbalanced, high-fat diet, some people with GERD are sensitive to particular foods—chocolate, garlic, spicy
foods, fried foods, and tomato-based foods—which worsen symptoms. Drinks containing alcohol or caffeine may also worsen
GERD symptoms. GERD is diagnosed most often by a history of the frequency of recurring symptoms. A more proper diagnosis
can be made when a doctor inserts a small device into the lower esophagus that measures the acidity of the contents during one’s
daily activities. About 50 percent of people with GERD have inflamed tissues in the esophagus.
The first approach to GERD treatment is dietary and lifestyle modifications. Suggestions are to reduce weight if you are overweight
or obese, avoid foods that worsen GERD symptoms, eat smaller meals, stop smoking, and remain upright for at least three hours
after a meal. People with GERD may not take in the nutrients they need because of the pain and discomfort associated with eating.
As a result, GERD can be caused by an unbalanced diet and its symptoms can lead to a worsening of nutrient inadequacy, a vicious
cycle that further compromises health. Some evidence from scientific studies indicates that medications used to treat GERD may
accentuate certain nutrient deficiencies, namely zinc and magnesium. When these treatment approaches do not work surgery is an
option. The most common surgery involves reinforcing the sphincter that serves as a barrier between the stomach and esophagus.

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is characterized by muscle spasms in the colon that result in abdominal pain, bloating, constipation,
and/or diarrhea. Interestingly, IBS produces no permanent structural damage to the large intestine as often happens to patients who
have Crohn’s disease or inflammatory bowel disease. It is estimated that one in five Americans displays symptoms of IBS. The
disorder is more prevalent in women than men. Two primary factors that contribute to IBS are an unbalanced diet and stress.
Symptoms of IBS significantly decrease a person’s quality of life as they are present for at least twelve consecutive or
nonconsecutive weeks in a year. Large meals and foods high in fat and added sugars, or those that contain wheat, rye, barley,
peppermint, and chocolate intensify or bring about symptoms of IBS. Additionally, beverages containing caffeine or alcohol may
worsen IBS. Stress and depression compound the severity and frequency of IBS symptoms. As with GERD, the first treatment
approaches for IBS are diet and lifestyle modifications. People with IBS are often told to keep a daily food journal to help identify
and eliminate foods that cause the most problems. Other recommendations are to eat slower, add more fiber to the diet, drink more

12.4.1 [Link]
water, and to exercise. There are some medications (many of which can be purchased over-the-counter) to treat IBS and the
resulting diarrhea or constipation. Sometimes antidepressants and drugs to relax the colon are prescribed.

Celiac Disease
Celiac disease is an autoimmune disorder affecting between 0.5 and 1.0 percent of Americans—that is, one in every one- to two-
hundred people. It is caused by an abnormal immune reaction of small intestine cells to a type of protein, called gluten. Gluten
forms in the presence of water and is composed of two protein parts, glutenin and gliadin. Glutenin and gliadin are found in grains
that are commonly used to make bread, such as wheat, rye, and barley. When bread is made, yeast eats the flour and makes a waste
product, carbon dioxide, which forms bubbles in the dough. As the dough is kneaded, gluten forms and stretches. The carbon
dioxide gas bubbles infiltrate the stretchy gluten, giving bread its porosity and tenderness. For those who are sensitive to gluten, it
is good to know that corn, millet, buckwheat, and oats do not contain the proteins that make gluten. However, some people who
have celiac disease also may have a response to products containing oats. This is most likely the result of cross-contamination of
grains during harvest, storage, packaging, and processing.
Celiac disease is most common in people of European descent and is rare in people of African American, Japanese, and Chinese
descent. It is much more prevalent in women and in people with Type 1 diabetes, autoimmune thyroid disease, and Down and
Turner syndromes. Symptoms can range from mild to severe and can include pale, fatty, loose stools, gastrointestinal upset,
abdominal pain, weight loss and, in children, a failure to grow and thrive. The symptoms can appear in infancy or much later in
life, even by age seventy. Celiac disease is not always diagnosed because the symptoms may be mild. A large number of people
have what is referred to as “silent” or “latent” celiac disease.
Celiac disease diagnosis requires a blood test and a biopsy of the small intestine. Because celiac disease is an autoimmune disease,
antibodies produced by white blood cells circulate in the body and can be detected in the blood. When gluten-containing foods are
consumed the antibodies attack cells lining the small intestine leading to a destruction of the small villi projections. This tissue
damage can be detected with a biopsy, a procedure that removes a portion of tissue from the damaged organ. Villi destruction is
what causes many of the symptoms of celiac disease. The destruction of the absorptive surface of the small intestine also results in
the malabsorption of nutrients, so that while people with this disease may eat enough, nutrients do not make it to the bloodstream
because absorption is reduced. The effects of nutrient malabsorption are most apparent in children and the elderly as they are
especially susceptible to nutrient deficiencies. Over time these nutrient deficiencies can cause health problems. Poor absorption of
iron and folic acid can cause anemia, which is a decrease in red blood cells. Anemia impairs oxygen transport to all cells in the
body. Calcium and vitamin D deficiencies can lead to osteoporosis, a disease in which bones become brittle.
If you think you or someone close to you may have celiac disease, do not despair; it is a very treatable disease. Once diagnosed, a
person follows a gluten-free diet for life. This requires dedication and careful detective work to seek out foods with hidden gluten,
but some stores carry gluten-free foods. After eliminating gluten from the diet, the tissues of the small intestine rapidly repair
themselves and heal in less than six months.

Food Allergies
Paying attention to the way individuals react to various foods is essential in determining what foods may specifically affect a
person adversely. Food allergies are one of the many ways in which different body make-ups affect nutritional concerns. Although
an estimated twelve million Americans have food allergies, there are likely many more people who say they have food allergies
than actually do. This is because food sensitization is different from a medically-determined food allergy. When someone has a
food allergy, the immune system mistakenly attacks a certain kind of food (usually the protein component of a food), such as
peanuts, as if it were a threat and IgE antibodies are produced. Doctors sometimes test for food allergies by using skin-prick tests or
blood tests to look for the presence of IgE antibodies. However, these types of tests are not always reliable as they can sometimes
yield a false positive result. By far, the most valuable tests for determining a food allergy is the Double Blind Placebo Controlled
Food Challenge (DBPCFC), which involves administering the food orally and then denoting the signs and symptoms of the allergic
response.
Food allergy symptoms usually develop within a few minutes to two hours after a person has eaten a food to which they are
allergic. These symptoms can range from the annoying to the potentially fatal, and include:
A tingling mouth

12.4.2 [Link]
 Swelling tongue and/or throat
Difficulty breathing
Hives
Stomach cramps
Diarrhea
Vomiting
Drop in blood pressure
Loss of consciousness
Death
There are no clear treatments for food allergies. Epinephrine is sometimes used to control severe reactions, and individuals with
known and dangerous allergies may get prescriptions for self-injectable devices. The only certain way to avoid allergic reactions to
food is to avoid the foods that cause them. Beyond avoidance, this can mean reading food labels carefully, or even calling
manufacturers for product information.
Ninety percent of food allergies are caused by these eight foods:
1. Milk
2. Eggs
3. Peanuts
4. Tree nuts
5. Fish
6. Shellfish
7. Wheat
8. Soy
The prevalence of food allergies is a complex and growing problem. In response to this situation, the National Institute of Allergy
and Infectious Diseases (NIAID) collaborated with thirty-four professional organizations, federal agencies, and patient-advocacy
groups to develop a comprehensive guide to diagnosing and managing food allergies and treating acute food allergy reactions. The
guide defines various food allergies, allergens, and reactions, provides comprehensive information on the prevalence of different
food allergies, tracks the history of food allergies, and reviews medical management techniques for people with food allergies.

Oral Disease
Oral health refers not only to healthy teeth and gums, but also to the health of all the supporting tissues in the mouth such as
ligaments, nerves, jawbone, chewing muscles, and salivary glands. Over ten years ago the Surgeon General produced its first report
dedicated to oral health, stating that oral health and health in general are not separate entities.[2]
Instead, oral health is an integral part of overall health and well-being. Soft drinks, sports drinks, candies, desserts, and fruit juices
are the main sources of “fermentable sugars” in the American diet. (Fermentable sugars are those that are easily metabolized by
bacteria in a process known as fermentation. Glucose, fructose, and maltose are three examples.) Bacteria that inhabit the mouth
metabolize fermentable sugars and starches in refined grains to acids that erode tooth enamel and deeper bone tissues. The acid
creates holes (cavities) in the teeth that can be extremely painful. Gums are also damaged by bacteria produced by acids, leading to
gingivitis (characterized by inflamed and bleeding gums). Saliva is actually a natural mouthwash that neutralizes the acids and aids
in building up teeth that have been damaged.

Figure : Gingivitis. “Gingivitis” / CC0 1.0

12.4.3 [Link]
According to Healthy People 2010, 23 percent of US children have cavities by the age of four, and by second grade, one-half of all
children in this country have at least one cavity.[3]
Cavities are an epidemic health problem in the United States and are associated with poor diet, but other contributors include poor
dental hygiene and the inaccessibility to regular oral health care. A review in Academic Pediatrics reports that “frequent
consumption of fast-releasing carbohydrates, primarily in the form of dietary sugars, is significantly associated with increased
dental caries risk.”[4] In regards to sugary soft drinks, the American Dental Association says that drinking sugary soft drinks
increases the risk of decay formation.[5]

Colon Health
A substantial health benefit of whole grain foods is that fiber actively supports digestion and optimizes colon health. (This can be
more specifically attributed to the insoluble fiber content of whole grains.) There is good evidence supporting that insoluble fiber
prevents the irritating problem of constipation and the development of diverticulosis and diverticulitis. Diverticulosis is a benign
condition characterized by outpouches of the colon. Diverticulitis occurs when the outpouches in the lining of the colon become
inflamed. Interestingly, diverticulitis did not make its medical debut until the early 1900s, and in 1971 was defined as a deficiency
of whole-grain fiber. According to the National Digestive Diseases Information Clearinghouse, 10 percent of Americans over the
age of forty have diverticulosis, and 50 percent of people over the age of sixty have the disorder.[6] Ten to 25 percent of people who
have diverticulosis go on to develop diverticulitis.[7] Symptoms include lower abdominal pain, nausea, and alternating between
constipation and diarrhea.
The chances of developing diverticulosis can be reduced with fiber intake because of what the breakdown products of the fiber do
for the colon. The bacterial breakdown of fiber in the large intestine releases short-chain fatty acids. These molecules have been
found to nourish colonic cells, inhibit colonic inflammation, and stimulate the immune system (thereby providing protection of the
colon from harmful substances). Additionally, the bacterial indigestible fiber, mostly insoluble, increases stool bulk and softness
increasing transit time in the large intestine and facilitating feces elimination. One phenomenon of consuming foods high in fiber is
increased gas, since the byproducts of bacterial digestion of fiber are gases.

Figure : Diverticulitis: A Disease of Fiber Deficiency. Image by Allison

Calabrese / CC BY 4.0
Some studies have found a link between high dietary-fiber intake and a decreased risk for colon cancer. However an analysis of
several studies, published in the Journal of the American Medical Association 2005, did not find that dietary-fiber intake was
associated with a reduction in colon cancer risk.[8] There is some evidence that specific fiber types (such as inulin) may protect
against colon cancer, but more studies are needed to conclusively determine how certain fiber types (and at what dose) inhibit colon
cancer development.

12.4.4 [Link]
Osteoporosis
There are several factors that lead to loss of bone quality during aging, including a reduction in hormone levels, decreased calcium
absorption, and increased muscle deterioration. It is comparable to being charged with the task of maintaining and repairing the
structure of your home without having all of the necessary materials to do so. However, you will learn that there are many ways to
maximize your bone health at any age.
Osteoporosis is the excessive loss of bone over time. It leads to decreased bone strength and an increased susceptibility to bone
fracture. The Office of the Surgeon General (OSG) reports that approximately ten million Americans over age fifty are living with
osteoporosis, and an additional thirty-four million have osteopenia, which is lower-than-normal bone mineral density.[9]
Osteoporosis is a debilitating disease that markedly increases the risks of suffering from bone fractures. A fracture in the hip causes
the most serious consequences—and approximately 20 percent of senior citizens who have one will die in the year after the injury.
Osteoporosis affects more women than men, but men are also at risk for developing osteoporosis, especially after the age of
seventy. These statistics may appear grim, but many organizations—including the National Osteoporosis Foundation and the OSG
—are disseminating information to the public and to health-care professionals on ways to prevent the disease, while at the same
time, science is advancing in the prevention and treatment of this disease.[10]
As previously discussed, bones grow and mineralize predominantly during infancy, childhood, and puberty. During this time, bone
growth exceeds bone loss. By age twenty, bone growth is fairly complete and only a small amount (about 10 percent) of bone mass
accumulates in the third decade of life. By age thirty, bone mass is at its greatest in both men and women and then gradually
declines after age forty. Bone mass refers to the total weight of bone tissue in the human body. The greatest quantity of bone tissue
a person develops during his or her lifetime is called peak bone mass. The decline in bone mass after age forty occurs because bone
loss is greater than bone growth. The increased bone degradation decreases the mineral content of bone tissue leading to a decrease
in bone strength and increased fracture risk.
Osteoporosis is referred to as a silent disease, much like high blood pressure, because symptoms are rarely exhibited. A person with
osteoporosis may not know he has the disease until he experiences a bone break or fracture. Detection and treatment of
osteoporosis, before the occurrence of a fracture, can significantly improve the quality of life. To detect osteopenia or osteoporosis,
BMD must be measured by the DEXA procedure.
During the course of osteoporosis, BMD decreases and the bone tissue microarchitecture is compromised. Excessive bone
resorption in the trabecular tissue increases the size of the holes in the lattice-like structure making it more porous and weaker. A
disproportionate amount of resorption of the strong cortical bone causes it to become thinner. The deterioration of one or both types
of bone tissue causes bones to weaken and, consequently, become more susceptible to fractures. The American Academy of
Orthopaedic Surgeons reports that one in two women and one in five men older than sixty-five will experience a bone fracture
caused by osteoporosis.[11]

12.4.5 [Link]
 Figure 18.3 Osteoporosis in Vertebrae. Image by BruceBlaus/ CC BY 4.0
When the vertebral bone tissue is weakened, it can cause the spine to curve. The increase in spine curvature not only causes pain,
but also decreases a person’s height. Curvature of the upper spine produces what is called Dowager’s hump, also known as
kyphosis. Severe upper-spine deformity can compress the chest cavity and cause difficulty breathing. It may also cause abdominal
pain and loss of appetite because of the increased pressure on the abdomen.

Risk Factors for Osteoporosis

A risk factor is defined as a variable that is linked to an increased probability of developing a disease or adverse outcome. Recall
that advanced age and being female increases the likelihood for developing osteoporosis. These factors present risks that should
signal doctors and individuals to focus more attention on bone health, especially when the risk factors exist in combination. This is
because not all risk factors for osteoporosis are out of your control. Risk factors such as age, gender, and race are biological risk
factors, and are based on genetics that cannot be changed. By contrast, there are other risk factors that can be modified, such as
physical activity, alcohol intake, and diet. The changeable risk factors for osteoporosis provide a mechanism to improve bone
health even though some people may be genetically predisposed to the disease.

Figure : Image by Tomasz Sienick / CC BY- SA 3.0

12.4.6 [Link]
Physical Activity
Bone is a living tissue, like muscle, that reacts to exercise by gaining strength. Physical inactivity lowers peak bone mass, decreases
BMD at all ages, and is linked to an increase in fracture risk, especially in the elderly. Recall that mechanical stress increases bone
remodeling and leads to increased bone strength and quality. Weight-bearing exercise puts mechanical stress on bones and therefore
increases bone quality. Weight-bearing exercises such as strength training with weights, and aerobic weight-bearing activities, such
as walking, running, and stair climbing are the most helpful for maintaining BMD. Certain aerobic exercises such as biking and
swimming do not build bones, although they are very good for cardiovascular [Link] stimulation of new bone growth occurs
when a person participates in weight-bearing or resistance activities that force the body to work against gravity. Research has
shown that this is an excellent way to activate osteoblasts to build more new bone. Conversely, physical inactivity lowers peak
bone mass, decreases BMD at all ages, and is linked to an increase in fracture risk, especially in the elderly.

Being Underweight
Being underweight significantly increases the risk for developing osteoporosis. This is because people who are underweight often
also have a smaller frame size and therefore have a lower peak bone mass. Maintaining a normal, healthy weight is important and
acts as a form of weight-bearing exercise for the skeletal system as a person moves about. Additionally, inadequate nutrition
negatively impacts peak bone mass and BMD. The most striking relationship between being underweight and bone health is seen in
people with the psychiatric illness anorexia nervosa. Anorexia nervosa is strongly correlated with low peak bone mass and a low
BMD. In fact, more than 50 percent of men and women who have this illness develop osteoporosis and sometimes it occurs very
early in life.[12] Women with anorexia nervosa are especially at risk because they not only have inadequate nutrition and low body
weight, but also the illness is also associated with estrogen deficiency.

Smoking, Alcohol, and Caffeine

Smoking cigarettes has long been connected to a decrease in BMD and an increased risk for osteoporosis and fractures. However,
because people who smoke are more likely to be physically inactive and have poor diets, it is difficult to determine whether
smoking itself causes osteoporosis. What is more, smoking is linked to earlier menopause and therefore the increased risk for
developing osteoporosis among female smokers may also be attributed, at least in part, to having stopped estrogen production at an
earlier age. A review of several studies, published in the British Medical Journal in 1997, reports that in postmenopausal women
who smoked, BMD was decreased an additional 2 percent for every ten-year increase in age and that these women had a substantial
increase in the incidence of hip fractures.[13]
Alcohol intake’s effect on bone health is less clear. In some studies, excessive alcohol consumption was found to be a risk factor for
developing osteoporosis, but the results of other studies suggests consuming two drinks per day is actually associated with an
increase in BMD and a decreased risk for developing osteoporosis. The International Osteoporosis Foundation states that
consuming more than two alcoholic drinks per day is a risk factor for developing osteoporosis and sustaining a hip fracture in both
men and women.[14] Moreover, excessive alcohol intake during adolescence and young adulthood has a more profound effect on
BMD and osteoporosis risk than drinking too much alcohol later in life.
Some studies have found that, similar to alcohol intake, excessive caffeine consumption has been correlated to decreased BMD, but
in other studies moderate caffeine consumption actually improves BMD. Overall, the evidence that caffeine consumption poses a
risk for developing osteoporosis is scant, especially when calcium intake is sufficient. Some evidence suggests that carbonated soft
drinks negatively affect BMD and increase fracture risk. Their effects, if any, on bone health are not attributed to caffeine content
or carbonation. It is probable that any effects of the excessive consumption of soft drinks, caffeinated or not, on bone health can be
attributed to the displacement of milk as a dietary source of calcium.

Nutrition
Ensuring adequate nutrition is a key component in maintaining bone health. Having low dietary intakes of calcium and vitamin D
are strong risk factors for developing osteoporosis. Another key nutrient for bone health is protein. Remember that the protein
collagen comprises almost one third of bone tissue. A diet inadequate in protein is a risk factor for osteoporosis. Multiple large
observational studies have shown that diets high in protein increase BMD and reduce fracture risk and that diets low in protein
correlate to decreased BMD and increased fracture risk. There has been some debate over whether diets super high in animal
protein decreases bone quality by stimulating bone resorption and increasing calcium excretion in the urine. A review in the May
2008 issue of the American Journal of Clinical Nutrition concludes that there is more evidence that diets adequate in protein play a

12.4.7 [Link]
role in maximizing bone health and there is little consistent evidence that suggests high protein diets negatively affect bone health
when calcium intake is adequate.[15]

Osteoporosis Prevention and Treatment

Although the symptoms of osteoporosis do not occur until old age, osteoporosis is referred to as a childhood disease with old-age
consequences. Thus, preventing osteoporosis in old age begins with building strong bones when you are growing. Remember, the
more bone mass a person has to start with, the greater the loss a person can withstand without developing osteopenia or
osteoporosis. Growing and maintaining healthy bones requires good nutrition, adequate intake of minerals and vitamins that are
involved in maintaining bone health, and weight-bearing exercise.
Prevention extends throughout life, and people with one or more risk factors for osteoporosis should have their BMD measured.
The National Osteoporosis Foundation recommends the following groups of people get BMD screening:[16]
Women who are sixty-five or older
Men who are seventy or older
Women and men who break a bone after age fifty
Women going through menopause with other risk factors
Men fifty to sixty-nine years of age with risk factors

References
1. Hampel H, Abraham NS, El-Serag HB. (2005). Meta-Analysis: Obesity and the Risk for Gastroesophageal Reflux Disease and
Its Complications. Annuals of Internal Medicine, 143(3), 199–211. [Link] Accessed
April 12, 2018. ↵
2. Office of the Surgeon General (US). National Call To Action To Promote Oral Health. National Institute of Dental and
Craniofacial Research (US). 2003; 03-5303. [Link] Accessed April 15, 2018. ↵
3. Continuing MCH Education in Oral Health. Oral Health and Health Care. [Link]
Accessed April 12, 2018. ↵
4. Mobley C, Marshall T. (2009). The Contribution of Dietary Factors to Dental Caries and Disparities in Caries. Academy of
Pediatrics, 9(6), 410–14. [Link] Accessed April 15, 2018. ↵
5. Foods that Affects your Teeth. American Dental Association. [Link] Accessed
April 15, 2018. ↵
6. Diverticular Disease. National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health.
[Link]/ddiseases/pubs/diverticulosis/. Accessed April 15, 2018. ↵
7. Diverticular Disease. National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health.
[Link]/ddiseases/pubs/diverticulosis/. Accessed April 15, 2018. ↵
8. Park Y, Hunter DJ. (2005). Dietary Fiber Intake and Risk of Colorectal Cancer. Journal of the American Medical Association,
294(22), 2849–57. [Link] Accessed April 15,2018. ↵
9. Office of the Surgeon General (US). Bone Health and Osteoporosis. 2004. [Link]
Accessed April 12,2018. ↵
10. Facts and Statistics. International Osteoporosis Foundation. [Link]
Accessed March 17, 2018. ↵
11. Osteoporosis. American Academy of Orthopaedic [Link]. [Link]/[Link]?topic=a00232. Updated
August 2009. Accessed April 16, 2018. ↵
12. Mehler PS, Weiner K. The Risk of Osteoporosis in Anorexia Nervosa. Eating Disorders Recovery Today.
[Link] Published May 14, 2017. Accessed April 15, 2018. ↵
13. Law MR, Hackshaw, AK. (1997). A Meta-Analysis of Cigarette Smoking, Bone Mineral Density and Risk of Hip Fracture:
Recognition of a Major Effect. British Medical Journal, 315 (7112), 841–6. [Link]
Accessed April 15, 2018. ↵
14. New IOF Report Shows Smoking, Alcohol, Being Underweight, and Poor Nutrition Harm Our Bones. International
Osteoporosis Foundation. [Link]/new-iof-report-shows-smoking-alcohol-being-underweight-and-poor-
nutrition-harm-our-bones. Published October 19, 2007. Accessed April 15, 2018. ↵

12.4.8 [Link]
15. Heaney, RP, Layman DK. (2008). Amount and Type of Protein Influences Bone Health. The American Journal of Clinical
Nutrition, 87(5), 1567S–70S. [Link]/content/87/5/[Link]. Accessed April 15, 2018. ↵
16. Bone Density Exam/Test. National Osteoporosis Foundation. [Link]
examtesting/. Accessed April 15, 2018. ↵

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Original source: [Link]

12.4.9 [Link]
12.5: Threats to Health
Chronic Diseases
Chronic diseases are ongoing, life-threatening, and life-altering health challenges. They are the leading cause of death worldwide.
Chronic conditions are increasing in frequency. They cause significant physical and emotional suffering and are an impediment to
economic growth and vitality. It is important, now more than ever, to understand the different risk factors for chronic disease and to
learn how to prevent their development.

The Risk Factors of Chronic Disease

A risk factor is a signal that your chances for acquiring a chronic disease may be increased. You might liken a risk factor to the
flags that lifeguards sometimes set up at beaches. When you see these flags, you know immediately that swimming within the
marked areas could be hazardous, and that if you choose to swim within these parameters anyway, you are doing so at your own
risk. But, if you heed the warnings, you are taking the necessary step to protect your safety and health. Similarly, risk factors are
warning signs that coincide with the development and progression of disease. However, risk factors are not a 100-percent guarantee
that a person will develop a chronic disease, only that the conditions are right. For example, if a person gets sick with the flu, we
can say with certainty that the illness was caused by a virus. However, we cannot say that a sedentary lifestyle caused the onset of
cardiovascular disease in a patient, because a risk factor indicates a correlation, not a causation.
Chronic disease usually develops alongside a combination of the following risk factors: genetics, a prior disease such as obesity or
hypertension, dietary and lifestyle choices, and environmental problems. Risk factors such as genetics and age cannot be changed.
However, some risk factors can be altered to promote health and wellness,such as diet. For example, a person who continuously
eats a diet high in sugars, saturated fats, and red meat is at risk for becoming obese and developing Type 2 diabetes, cardiovascular
disease, or several other conditions. Making more healthy dietary choices can greatly reduce that risk. Being a woman over age
sixty-five is a risk factor for developing osteoporosis, but that cannot be changed. Also, people without a genetic predisposition for
a particular chronic illness can still develop it. Not having a genetic predisposition for a chronic disease is not a guarantee of
immunity.

Identifying Your Risk Factors

To estimate your own risk factors for developing certain chronic diseases, search through your family’s medical history. What
diseases do you note showing up among close blood relatives? At your next physical, pay attention to your blood tests and ask the
doctor if any results are out of normal range. It is also helpful to note your vital signs, particularly your blood pressure and resting
heart rate. In addition, you may wish to keep a food diary to make a note of the dietary choices that you make on a regular basis
and be aware of foods that are high in saturated fat, among other unhealthy options. As a general rule, it is important to look for risk
factors that you can modify to promote your health. For example, if you discover that your grandmother, aunt, and uncle all
suffered from high blood pressure, then you may decide to avoid a high sodium diet. Identifying your risk factors can arm you with
the information you need to help ward off disease.

The Crisis of Obesity

Excessive weight gain has become an epidemic. According to the National Institutes of Health, over two-thirds of American adults
are overweight, and one in three is obese. Obesity in particular puts people at risk for a host of complications, including Type 2
diabetes, heart disease, high cholesterol, hypertension, osteoarthritis, and some forms of cancer. The more overweight a person is,
the greater his or her risk of developing life-threatening complications. There is no single cause of obesity and no single way to
treat it. However, a healthy, nutritious diet is generally the first step, including consuming more fruits and vegetables, whole grains,
and lean meats and dairy products.[1]

Cardiovascular Disease
Throughout the remainder of this section, we will examine some of the more prevalent chronic diseases, their risk factors, and the
choices that can help to discourage their development or progression. Let’s begin with cardiovascular disease. According to the
Centers for Disease Control and Prevention (CDC), heart disease is the leading cause of death in the United States.[2]

12.5.1 [Link]
The disease generally starts with atherosclerosis, or a hardening of the arteries, a chronic condition so common that most people
show signs of it by the time they turn thirty. Arteries start to narrow and harden when fats accumulate along their inner walls and
form plaques. A plaque is made of fat, cholesterol, calcium, and other substances found in blood.
Plaque formation causes arteries to narrow and harden, which elevates blood pressure because the vessels can’t expand effectively
to accommodate blood pulses. Higher blood pressure strains the heart and causes more damage. Arterial walls can become so
weakened due to high blood pressure that they balloon and form what is known as an aneurysm. If the aneurysm bursts, it becomes
a life-threatening event. The plaques themselves can also rupture due to a spike in blood pressure or a tremor along an arterial wall,
and the body responds to this perceived injury by forming blood clots. These clots are serious health threats, whether they are
stationary (a thrombus) or moving (an embolus). A stable clot can slowly kill off surrounding tissue, or grow so big that it blocks
blood circulation and causes thrombosis. When a moving clot becomes stuck in an artery too small for its passage, it cuts off blood
flow and causes cell death. This is referred to as an embolism. Blood clots in heart and brain arteries can cause heart attacks or
strokes.
Table : The Risk Factors for Cardiovascular Disease
Unmodifiable Risk Factors Modifiable Risk Factors

Cigarette smoking. Nicotine constricts blood vessels, and

carbon monoxide damages their inner lining, which increases
the risk of atherosclerosis.
Obesity. Excess weight worsens other risk factors.
Age. Risk increases for men at forty-five, and for women at Diabetes. This condition is associated with an increased risk of
fifty-five. heart disease. Both types have certain risk factors in common,
Sex. Men have a higher risk than women, though the risk for including obesity and high blood pressure.
women steeply rises after menopause. Physical inactivity. Lack of exercise is associated with heart
Family history. The more family members who have heart disease.
disease, the greater the risk. Cholesterol levels. High levels of blood cholesterol can
increase the risk. A high level of low-density lipoprotein
(LDL), or the “bad” cholesterol, is a common contributing
factor. However, a low level of high-density lipoprotein (HDL),
or “good” cholesterol, can also promote atherosclerosis.

Steps to Reducing the Risk of Cardiovascular Disease

Diet and nutrition can play a significant role in reducing the risk of cardiovascular disease. It is helpful to lower sodium intake,
increase consumption of dietary fiber, and limit consumption of saturated fat, which promotes plaque formation. In addition, it is
important to replace refined starches and added sugar, which can boost triglycerides, with whole grains, fruits, and vegetables.
Eating foods rich in omega-3 fatty acids, especially fish, using alcohol in moderation, and opting for low or no-fat dairy products
can all help reduce your cardiovascular disease risk. Emphasizing vegetable-based sources of protein, such as beans and legumes,
can be beneficial, as well as consuming more soy products. It is also important to maintain a healthy weight and avoid smoking or
chewing tobacco.

Hypertension
Chronic high blood pressure, also known as hypertension, is a significant health hazard affecting one out of three adults in the
United States.[3] This chronic condition is a major cause of heart attacks and strokes, yet it has no symptoms until blood pressure
reaches very high levels, which is why it is known as “the silent killer.” The only way to find out if you have high blood pressure is
to get an accurate reading of your resting blood pressure rate, which is best done by a medical professional and should be
monitored regularly.
High blood pressure is such an important factor in cardiovascular disease, that keeping it within a healthy range is vitally important.
Blood pressure readings consist of two numbers. The top number measures systolic pressure (when the heart contracts) and the
bottom number measures diastolic pressure (when the heart is at rest). The key blood pressure numbers to keep in mind are:
Ideal. 120 over 80 or below

12.5.2 [Link]
 Prehypertension. Higher than 120 over 80 and lower than 139 over 89
Hypertension. Greater than 139 over 89
Table : The Risk Factors for Hypertension

Unmodifiable Risk Factors Modifiable Risk Factors

Age. After fifty-five, the risk of developing high blood Weight. Roughly 60 percent of people with hypertension are
pressure is 90 percent. obese.
Race. African-Americans are more likely to develop Sodium consumption. The more salt in a person’s diet, the
hypertension, manifest it at a younger age, and have higher more likely they are to have high blood pressure.
blood pressure readings. Alcohol. Drinking more than two drinks per day for men and
Family history. There is a strong genetic component to high one drink for women increases the likelihood of hypertension.
blood pressure, and an individual’s risk goes up along with the Diet. In addition to salt and alcohol consumption, other dietary
number of family members who have hypertension. factors increase chances of developing hypertension.

Steps to Reducing the Risk of High Blood Pressure

Although it is not possible to change one’s age or genetics, there are actions that people can take to decrease their risk of
hypertension. Techniques to reduce blood pressure include becoming physically active, maintaining a healthy weight, reducing
sodium intake below 2,400 milligrams per day (or below 1,500 milligrams if you are in a high-risk group or already have been
diagnosed with hypertension), using alcohol moderately, and following the DASH diet. Additionally, vitamin C, calcium, and
potassium have all been shown to promote healthy blood pressure. It is also vital to monitor your blood pressure levels on a regular
basis. Prompt intervention when readings rise above the ideal level (120 over 80) can save lives, which is why everyone should
know the status of their blood pressure.

Cancer
More than one hundred diseases are classified as different forms of cancer, all of them characterized by the uncontrolled growth of
abnormal cells. Cancer is triggered by mutations in a cell’s genetic material. The cause of these changes may be inherited, or it may
result from exposure to carcinogens, which are agents that can cause cancer. Carcinogens include chemicals, viruses, certain
medical treatments such as radiation, pollution, or other substances and exposures that are known or suspected to cause cancer.[4]
The National Institutes of Health has classified fifty-four different compounds as known cancer-causing agents in humans.[5]
Under normal conditions, a healthy cell will either repair any damage that has been done or self destruct so that no future cells will
be affected. Cells become cancerous when their DNA is damaged, but they do not self-destruct or stop reproducing as normal cells
would. As these abnormal cells continue their rapid growth, in most cancers they coalesce in a mass called a tumor. Cancer cells
can overwhelm healthy cells and interfere with the healthy functioning of the body. They can also invade other organs and spread
throughout the body in a process known as metastasis. Scientists and the medical community are giving considerable attention to
the early stages of cancer, from the moment a healthy cell is exposed to a carcinogen to the point where cells with damaged DNA
are replicating out of control. Intervention at any of these early stages could prove to be quite beneficial, because it is thought that
most cancers are the result of lifestyle choices and environmental exposure.
The risk factors for different cancers can vary. For example, exposure to ultraviolet radiation from the sun and from tanning beds is
a risk factor for skin cancer, while exposure to asbestos is a risk factor for mesothelioma cancer. Table shows some common
risk factors for a number of different types of cancer.
Table : The Risk Factors for Cancer

12.5.3 [Link]
 Unmodifiable Risk Factors Modifiable Risk Factors

Tobacco. Smoking or chewing tobacco greatly increases the

risk for certain cancers, including cancer of the lungs, bladder,
cervix, kidneys, mouth, and pancreas.
Alcohol. Drinking alcohol is linked to cancers of the mouth,
throat, esophagus, and breast, as well as to cancers of the neck
and head.
Obesity. Linked to cancers of the colon, uterus, pancreas,
esophagus, kidney, and breast.
Cooking techniques. Grilling, smoking, and preparing meat at
high temperatures forms carcinogens.
Age. Most cancers occur in people over the age of sixty-five.
Red meat. The risk of colon cancer seems to increase with the
However, people of all ages, including children, can get
consumption of red meat and processed meat.
cancer.
Cured meats. According to a recent study, there is a mild risk of
Family history. Certain types of cancer have a genetic link.
pancreatic cancer with the consumption of cured meats, such as
However, environmental factors may also play a part.
sausage, pepperoni, bacon, ham, smoked turkey, salami, and
hot dogs.
Physical inactivity. Linked to colon, breast, and other cancers.
Exposure to chemicals. People who have jobs that expose them
to chemicals on a regular basis, such as construction workers
and painters, have an increased risk of cancer.
Viruses or bacteria. Certain viruses or bacteria may increase the
risk of developing cancer. For example, human
papillomaviruses, which are sexually transmitted, are the
primary cause of cervical cancer.

Steps to Reducing the Risk of Cancer

According to the American Cancer Society, half of all American men and one-third of American women will be diagnosed with
some form of cancer in their lifetime.[6] Although cancer is one of the leading causes of death worldwide, ongoing research and
innovations in treatment have improved the outlook for cancer patients to the point where millions now survive or live with cancer,
making it a chronic disease.
The American Institute for Cancer Research (AICR) has published guidelines for preventing cancer and staying healthy. They
include several dietary and lifestyle choices, such as participating in physical activity for thirty minutes per day or more, and
maintaining a healthy weight. In addition, AICR recommends consuming a plant-based diet.[7]
Several epidemiological studies have found a link between eating plenty of fruits and vegetables and a low incidence of certain
cancers. Fruits and vegetables containing a wide variety of nutrients and phytochemicals may either prevent or reduce the oxidative
damage to cell structures. Cruciferous vegetables, such as cauliflower, broccoli, and Brussels sprouts, may also reduce the risk of
certain cancers, such as endometrial, esophageal, and others. Also, studies have shown that the more fiber you have in your diet, the
lower your risk of colon cancer.
Supplementation may also be helpful to a limited degree. Vitamin D and antioxidants have been linked to lowering the risk of some
cancers (however taking an iron supplement may promote others), but, obtaining vital nutrients from food first is the best way to
help prevent or manage cancer. In addition, regular and vigorous exercise can lower the risk of breast and colon cancers, among
others. Also, wear sunblock, stay in the shade, and avoid the midday sun to protect yourself from skin cancer, which is one of the
most common kinds of cancer.[8]

Diabetes

12.5.4 [Link]
What Is Diabetes?
Diabetes is one of the top three diseases in America. It affects millions of people and causes tens of thousands of deaths each year.
Diabetes is a metabolic disease of insulin deficiency and glucose over-sufficiency. Like other diseases, genetics, nutrition,
environment, and lifestyle are all involved in determining a person’s risk for developing diabetes. One sure way to decrease your
chances of getting diabetes is to maintain an optimal body weight by adhering to a diet that is balanced in carbohydrate, fat, and
protein intake. There are three different types of diabetes: Type 1 diabetes, Type 2 diabetes, and gestational diabetes.

Type 1 Diabetes
Type 1 diabetes is a metabolic disease in which insulin-secreting cells in the pancreas are killed by an abnormal response of the
immune system, causing a lack of insulin in the body. Its onset typically occurs before the age of thirty. The only way to prevent the
deadly symptoms of this disease is to inject insulin under the skin.
A person with Type 1 diabetes usually has a rapid onset of symptoms that include hunger, excessive thirst and urination, and rapid
weight loss. Because the main function of glucose is to provide energy for the body, when insulin is no longer present there is no
message sent to cells to take up glucose from the blood. Instead, cells use fat and proteins to make energy, resulting in weight loss.
If Type 1 diabetes goes untreated individuals with the disease will develop a life-threatening condition called ketoacidosis. This
condition occurs when the body uses fats and not glucose to make energy, resulting in a build-up of ketone bodies in the blood. It is
a severe form of ketosis with symptoms of vomiting, dehydration, rapid breathing, and confusion and eventually coma and death.
Upon insulin injection these severe symptoms are treated and death is avoided. Unfortunately, while insulin injection prevents
death, it is not considered a cure. People who have this disease must adhere to a strict diet to prevent the development of serious
complications. Type 1 diabetics are advised to consume a diet low in the types of carbohydrates that rapidly spike glucose levels
(high-GI foods), to count the carbohydrates they eat, to consume healthy-carbohydrate foods, and to eat small meals frequently.
These guidelines are aimed at preventing large fluctuations in blood glucose. Frequent exercise also helps manage blood-glucose
levels. Type 1 diabetes accounts for between 5 and 10 percent of diabetes cases.

Type 2 Diabetes
The other 90 to 95 percent of diabetes cases are Type 2 diabetes. Type 2 diabetes is defined as a metabolic disease of insulin
insufficiency, but it is also caused by muscle, liver, and fat cells no longer responding to the insulin in the body (Figure 18.4 . In
brief, cells in the body have become resistant to insulin and no longer receive the full physiological message of insulin to take up
glucose from the blood. Thus, similar to patients with Type 1 diabetes, those with Type 2 diabetes also have high blood-glucose
levels.

12.5.5 [Link]
 Figure : Healthy Individuals and Type 2 Diabetes. Image by
Allison Calabrese / CC BY 4.0
For Type 2 diabetics, the onset of symptoms is more gradual and less noticeable than for Type 1 diabetics. The first stage of Type 2
diabetes is characterized by high glucose and insulin levels. This is because the insulin-secreting cells in the pancreas attempt to
compensate for insulin resistance by making more insulin. In the second stage of Type 2 diabetes, the insulin-secreting cells in the
pancreas become exhausted and die. At this point, Type 2 diabetics also have to be treated with insulin injections. Healthcare
providers is to prevent the second stage from happening. As with Type 1 diabetes, chronically high-glucose levels cause big
detriments to health over time, so another goal for patients with Type 2 diabetes is to properly manage their blood-glucose levels.
The front-line approach for treating Type 2 diabetes includes eating a healthy diet and increasing physical activity.
The Centers for Disease Control Prevention (CDC) estimates that as of 2010, 25.8 million Americans have diabetes, which is 8.3
percent of the population.[9] In 2007 the cost of diabetes to the United States was estimated at $174 billion.[10] The incidence of
Type 2 diabetes has more than doubled in America in the past thirty years and the rise is partly attributed to the increase in obesity
in this country. Genetics, environment, nutrition, and lifestyle all play a role in determining a person’s risk for Type 2 diabetes. We
have the power to change some of the determinants of disease but not others. The Diabetes Prevention Trial that studied lifestyle
and drug interventions in more than three thousand participants who were at high risk for Type 2 diabetes found that intensive
lifestyle intervention reduced the chances of getting Type 2 diabetes by 58 percent.[11]

Gestational Diabetes
During pregnancy some women develop gestational diabetes. Gestational diabetes is characterized by high blood-glucose levels
and insulin resistance. The exact cause is not known but does involve the effects of pregnancy hormones on how cells respond to
insulin. Gestational diabetes can cause pregnancy complications and it is common practice for healthcare practitioners to screen
pregnant women for this metabolic disorder. The disorder normally ceases when the pregnancy is over, but the National Diabetes
Information Clearing House notes that women who had gestational diabetes have between a 40 and 60 percent likelihood of
developing Type 2 diabetes within the next ten years.[12] Gestational diabetes not only affects the health of a pregnant woman but
also is associated with an increased risk of obesity and Type 2 diabetes in her child.

Prediabetes
As the term infers, prediabetes is a metabolic condition in which people have moderately high glucose levels, but do not meet the
criteria for diagnosis as a diabetic. Over seventy-nine million Americans are prediabetic and at increased risk for Type 2 diabetes

12.5.6 [Link]
and cardiovascular disease.[13] The National Diabetes Information Clearing House reports that 35 percent of adults aged twenty and
older, and 50 percent of those over the age of sixty-five have prediabetes.[14]

Long-Term Health Consequences of Diabetes

The long-term health consequences of diabetes are severe. They are the result of chronically high glucose concentrations in the
blood accompanied by other metabolic abnormalities such as high blood-lipid levels. People with diabetes are between two and
four times more likely to die from cardiovascular disease. Diabetes is the number one cause of new cases of blindness, lower-limb
amputations, and kidney failure. Many people with diabetes develop peripheral neuropathy, characterized by muscle weakness, loss
of feeling and pain in the lower extremities. More recently, there is scientific evidence to suggest people with diabetes are also at
increased risk for Alzheimer’s disease.

Diabetes Treatment
Keeping blood-glucose levels in the target range (70–130 mg/dL before a meal) requires careful monitoring of blood-glucose levels
with a blood-glucose meter, strict adherence to a healthy diet, and increased physical activity. Type 1 diabetics begin insulin
injections as soon as they are diagnosed. Type 2 diabetics may require oral medications and insulin injections to maintain blood-
glucose levels in the target range. The symptoms of high blood glucose, also called hyperglycemia, are difficult to recognize,
diminish in the course of diabetes, and are mostly not apparent until levels become very high. The symptoms are increased thirst
and frequent urination. Having too low blood glucose levels, known as hypoglycemia, is also detrimental to health. Hypoglycemia
is more common in Type 1 diabetics and is most often caused by injecting too much insulin or injecting it at the wrong time. The
symptoms of hypoglycemia are more acute including shakiness, sweating, nausea, hunger, clamminess, fatigue, confusion,
irritability, stupor, seizures, and coma. Hypoglycemia can be rapidly and simply treated by eating foods containing about ten to
twenty grams of fast-releasing carbohydrates. If symptoms are severe a person is either treated by emergency care providers with
an intravenous solution of glucose or given an injection of glucagon, which mobilizes glucose from glycogen in the liver. Some
people who are not diabetic may experience reactive hypoglycemia. This is a condition in which people are sensitive to the intake
of sugars, refined starches, and high GI foods. Individuals with reactive hypoglycemia have some symptoms of hypoglycemia.
Symptoms are caused by a higher than normal increase in blood-insulin levels. This rapidly decreases blood-glucose levels to a
level below what is required for proper brain function.
The major determinants of Type 2 diabetes that can be changed are overnutrition and a sedentary lifestyle. Therefore, reversing or
improving these factors by lifestyle interventions markedly improve the overall health of Type 2 diabetics and lower blood-glucose
levels. In fact it has been shown that when people are overweight, losing as little as nine pounds (four kilograms) decreases blood-
glucose levels in Type 2 diabetics. The Diabetes Prevention Trial demonstrated that by adhering to a diet containing between 1,200
and 1,800 kilocalories per day with a dietary fat intake goal of less than 25 percent and increasing physical activity to at least 150
minutes per week, people at high risk for Type 2 diabetes achieved a weight loss of 7 percent and significantly decreased their
chances of developing Type 2 diabetes.[15]
The American Diabetes Association (ADA) has a website that provides information and tips for helping diabetics answer the
question, “What Can I Eat”. In regard to carbohydrates the ADA recommends diabetics keep track of the carbohydrates they eat
and set a limit. These dietary practices will help keep blood-glucose levels in the target range.

12.5.7 [Link]
 Figure : Metabolic Syndrome: A Combination of Risk Factors
Increasing the Chances for Chronic Disease. Image by Allison Calabrese / CC BY 4.0
Having more than one risk factor for Type 2 diabetes substantially increases a person’s chances for developing the disease.
Metabolic syndrome refers to a medical condition in which people have three or more risk factors for Type 2 diabetes and
cardiovascular disease. According to the International Diabetes Federation (IDF) people are diagnosed with this syndrome if they
have central (abdominal) obesity and any two of the following health parameters: triglycerides greater than 150 mg/dL; high
density lipoproteins (HDL) lower than 40 mg/dL; systolic blood pressure above 100 mmHg, or diastolic above 85 mmHg; fasting
blood-glucose levels greater than 100 mg/dL.[16] The IDF estimates that between 20 and 25 percent of adults worldwide have
metabolic syndrome. Studies vary, but people with metabolic syndrome have between a 9 and 30 times greater chance for
developing Type 2 diabetes than those who do not have the syndrome.[17]

 Everyday Connection

In 2010, the Pacific Islands Health Officers Association declared a regional state of health emergency for the epidemic of
chronic diseases in the United States Affiliated Pacific (USAP). Due to the high risk factors that many of these Pacific
Islanders, the leading cause of mortality of adults in the USAP from chronic diseases. To learn more about this declaration,
visit [Link]/fullsite/newsroom/wp-content/uploads/downloads/2012/06/NCD_Emergency_Declaration.pdf

Disease Prevention and Management

Eating fresh, healthy foods not only stimulates your taste buds, but also can improve your quality of life and help you to live
longer. As discussed, food fuels your body and helps you to maintain a healthy weight. Nutrition also contributes to longevity and
plays an important role in preventing a number of diseases and disorders, from obesity to cardiovascular disease. Some dietary
changes can also help to manage certain chronic conditions, including high blood pressure and diabetes. A doctor or a nutritionist
can provide guidance to determine the dietary changes needed to ensure and maintain your health.

References
1. Overweight and Obesity [Link] Institute of Diabetes and Digestive and Kidney Diseases.
[Link] Accessed April 15, 2018. ↵
2. Leading Causes of Death. [Link]. [Link] Updated March 17, 2017.
Accessed April 15, 2018. ↵
3. High Blood Pressure Facts. Center for Disease Control and Prevention. [Link] Updated
April 5, 2018. Accessed April 15, 2018. ↵
4. Known and Probable Human Carcinogens. American Cancer
[Link]://[Link]/Cancer/CancerCauses/OtherCarcinogens/GeneralInformationaboutCarcinogens/known-and-
probable -human-carcinogens. Updated November 3, 2016. Accessed April 15, 2018. ↵
5. Israel B. How Many Cancers Are Caused by the Environment?. [Link]
are-caused-by-the-environment. Published May 10, 2010. Accessed April 15, 2018. ↵

12.5.8 [Link]
 6. What Is Cancer? American Cancer Society. [Link] Updated December 8,
2015. Accessed April 15, 2018. ↵
7. Cancer Prevention and Early Detection Facts and Figures 2013. American Cancer Society.
[Link]
facts-and-figures/[Link]. Published 2013. Accessed April 15, 2018.
↵
8. Cancer Prevention: 7 Steps to Reduce Your Risk. Mayo Clinic. [Link]/health/cancer -prevention/CA00024.
Updated November 29, 2017. Accessed April 15, 2018. ↵
9. Diabetes Research and [Link] for Disease Control and Prevention. [Link]
Updated March 14, 2018. Accessed April 15, 2018. ↵
10. Diabetes Quick Facts. Centers for Disease Control and Prevention. [Link]
Updated July 24, 2017. Accessed April 15, 2018. ↵
11. Knowler WC. (2002). Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. The New
England Journal of Medicine, 346(6), 393–403. [Link] Accessed April 15,
2018. ↵
12. Diabetes Overview. National Institute of Diabetes and Digestive and Kidney Disease. [Link]
information/diabetes/overview. Accessed April 15, 2018. ↵
13. Diabetes Overview. National Institute of Diabetes and Digestive and Kidney Disease. [Link]
information/diabetes/overview. Accessed April 15, 2018. ↵
14. Diabetes Overview. National Institute of Diabetes and Digestive and Kidney Disease. [Link]
information/diabetes/overview. Accessed April 15, 2018. ↵
15. Knowler WC. (2002). Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. The New
England Journal of Medicine, 346(6), 393–403. [Link] Accessed April 15,
2018. ↵
16. The IDF Consensus Worldwide Definition of the Metabolic Syndrome. International Diabetes [Link]/our-
activities/advocacy-awareness/resources-and-tools/60:[Link].
Accessed April 15, 2018. ↵
17. The IDF Consensus Worldwide Definition of the Metabolic Syndrome. International Diabetes [Link]/our-
activities/advocacy-awareness/resources-and-tools/60:[Link].
Accessed April 15, 2018. ↵

This page titled 12.5: Threats to Health is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer
Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts
platform.
18.5: Threats to Health by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original
source: [Link]

12.5.9 [Link]
12.6: Undernutrition, Overnutrition, and Malnutrition
For many, the word “malnutrition” produces an image of a child in a third-world country with a bloated belly, and skinny arms and
legs. However, this image alone is not an accurate representation of the state of malnutrition. For example, someone who is 150
pounds overweight can also be malnourished.
Malnutrition refers to one not receiving proper nutrition and does not distinguish between the consequences of too many nutrients
or the lack of nutrients, both of which impair overall health. Undernutrition is characterized by a lack of nutrients and insufficient
energy supply, whereas overnutrition is characterized by excessive nutrient and energy intake. Overnutrition can result in obesity, a
growing global health threat. Obesity is defined as a metabolic disorder that leads to an overaccumulation of fat tissue.
Although not as prevalent in America as it is in developing countries, undernutrition is not uncommon and affects many
subpopulations, including the elderly, those with certain diseases, and those in poverty. Many people who live with diseases either
have no appetite or may not be able to digest food properly. Some medical causes of malnutrition include cancer, inflammatory
bowel syndrome, AIDS, Alzheimer’s disease, illnesses or conditions that cause chronic pain, psychiatric illnesses, such as anorexia
nervosa, or as a result of side effects from medications. Overnutrition is an epidemic in the United States and is known to be a risk
factor for many diseases, including Type 2 diabetes, cardiovascular disease, inflammatory disorders (such as rheumatoid arthritis),
and cancer.

Health Risks of Being Underweight

The 2003–2006 National Health and Nutrition Examination Survey (NHANES) estimated that 1.8 percent of adults and 3.3 percent
of children and adolescents in the United States are underweight.[1]
Being underweight is linked to nutritional deficiencies, especially iron-deficiency anemia, and to other problems such as delayed
wound healing, hormonal abnormalities, increased susceptibility to infection, and increased risk of some chronic diseases such as
osteoporosis. In children, being underweight can stunt growth. The most common underlying cause of underweight in America is
inadequate nutrition. Other causes are wasting diseases, such as cancer, multiple sclerosis, tuberculosis, and eating disorders.
People with wasting diseases are encouraged to seek nutritional counseling, as a healthy diet greatly affects survival and improves
responses to disease treatments. Eating disorders that result in underweight affect about eight million Americans (seven million
women and one million men).

Anorexia Nervosa
Anorexia nervosa, more often referred to as “anorexia,” is a psychiatric illness in which a person obsesses about their weight and
about food that they eat. Anorexia results in extreme nutrient inadequacy and eventually to organ malfunction. Anorexia is
relatively rare—the National Institute of Mental Health (NIMH) reports that 0.9 percent of females and 0.3 percent of males will
have anorexia at some point in their lifetime, but it is an extreme example of how an unbalanced diet can affect health.[2]
Anorexia frequently manifests during adolescence and it has the highest rate of mortality of all mental illnesses. People with
anorexia consume, on average, fewer than 1,000 kilocalories per day and exercise excessively. They are in a tremendous caloric
imbalance. Moreover, some may participate in binge eating, self-induced vomiting, and purging with laxatives or enemas. The very
first time a person starves him- or herself may trigger the onset of anorexia. The exact causes of anorexia are not completely
known, but many things contribute to its development including economic status, as it is most prevalent in high-income families. It
is a genetic disease and is often passed from one generation to the next. Pregnancy complications and abnormalities in the brain,
endocrine system, and immune system may all contribute to the development of this illness.
The primary signs of anorexia are fear of being overweight, extreme dieting, an unusual perception of body image, and depression.
The secondary signs and symptoms of anorexia are all related to the caloric and nutrient deficiencies of the unbalanced diet and
include excessive weight loss, a multitude of skin abnormalities, diarrhea, cavities and tooth loss, osteoporosis, and liver, kidney,
and heart failure. There is no physical test that can be used to diagnose anorexia and distinguish it from other mental illnesses.
Therefore a correct diagnosis involves eliminating other mental illnesses, hormonal imbalances, and nervous system abnormalities.
Eliminating these other possibilities involves numerous blood tests, urine tests, and x-rays. Coexisting organ malfunction is also
examined. Treatment of any mental illness involves not only the individual, but also family, friends, and a psychiatric counselor.
Treating anorexia also involves a dietitian, who helps to provide dietary solutions that often have to be adjusted over time. The

12.6.1 [Link]
goals of treatment for anorexia are to restore a healthy body weight and significantly reduce the behaviors associated with causing
the eating disorder. Relapse to an unbalanced diet is high. Many people do recover from anorexia, however most continue to have a
lower-than-normal body weight for the rest of their lives.

Bulimia Nervosa
Bulimia nervosa, like anorexia, is a psychiatric illness that can have severe health consequences. The NIMH reports that 0.5
percent of females and 0.1 percent of males will have bulimia nervosa, or otherwise known as bulimia, at some point in their
lifetime.[3]
Bulimia is characterized by episodes of eating large amounts of food followed by purging, which is accomplished by vomiting and
with the use of laxatives and diuretics. Unlike people with anorexia, those with bulimia often have a normal weight, making the
disorder more difficult to detect and diagnose. The disorder is characterized by signs similar to anorexia such as fear of being
overweight, extreme dieting, and bouts of excessive exercise. Secondary signs and symptoms include gastric reflux, severe erosion
of tooth enamel, dehydration, electrolyte imbalances, lacerations in the mouth from vomiting, and peptic ulcers. Repeated damage
to the esophagus puts people with bulimia at an increased risk for esophageal cancer. The disorder is also highly genetic, linked to
depression and anxiety disorders, and most commonly occurs in adolescent girls and young women. Treatment often involves
antidepressant medications and, like anorexia, has better results when both the family and the individual with the disorder
participate in nutritional and psychiatric counseling.

Binge-Eating Disorder
Similar to those who experience anorexia and bulimia, people who have a binge-eating disorder have lost control over their eating.
Binge-eating disorder is not currently diagnosed as a distinct psychiatric illness, although there is a proposal from the American
Psychiatric Association to categorize it more specifically. People with binge-eating disorder will periodically overeat to the
extreme, but their loss of control over eating is not followed by fasting, purging, or compulsive exercise. As a result, people with
this disorder are often overweight or obese, and their chronic disease risks are those linked to having an abnormally high body
weight such as hypertension, cardiovascular disease, and Type 2 diabetes. Additionally, they often experience guilt, shame, and
depression. Binge-eating disorder is commonly associated with depression and anxiety disorders. According to the NIMH, binge-
eating disorder is more prevalent than anorexia and bulimia, and affects 3.5 percent of females and 2.0 percent of males at some
point during their lifetime.[4] Treatment often involves antidepressant medication as well as nutritional and psychiatric counseling.

Orthorexia Nervosa
Orthorexia nervosa was coined in 1997 by physician Steven Bratman.[5] The term uses “ortho,” in its meaning as straight, correct
and true and refers to a fixation on eating proper food.[6] Fixation on ‘healthy eating’ by those with orthorexia nervosa often results
in behaviors that end up damaging one’s well-being such as extreme weight loss or a refusal to dine out with friends. Orthorexia
nervosa like anorexia nervosa involves restriction of the amount and variety of foods eaten, however those with orthorexia nervosa
do not have an incessant fear of weight gain but instead have an obsession with “feeling pure, healthy and natural.”[7] People
affected by orthorexia nervosa tend to follow diets tied to a philosophy or theory and believe that their theory of eating is the best.
[8][9]
Such diets often have a redemptive quality that involves denying oneself of “bad” or “wrong” foods.[10] In extreme cases,
affected individuals may also fear contamination or harm from water and electricity leading them to use filters to purify their
environment from electrical emissions. Orthorexia nervosa has similar physical consequences to anorexia nervosa despite the lack
of motivation for weight loss by affected individuals.
Although awareness of orthorexia nervosa is increasing, it is not formally recognized in the Diagnostic Statistical Manual and thus
it is difficult to get an estimate of how many persons are affected by orthorexia nervosa. Additionally, the lack of formal diagnostic
criteria makes it impossible to know if orthorexia nervosa occurs with other types of existing disorders like anorexia or a form of
obsessive-compulsive disorder (OCD) or if it’s a stand-alone eating disorder. Studies show that many persons with orthorexia
nervosa also have OCD. Many experts view orthorexia nervosa as a variety of anorexia or OCD. Treatment usually involves
psychotherapy and weight restoration as needed.[11] OCD may be a consequence of malnutrition, being underweight and a starved
brain thus weight restoration may resolve the OCD.
Warning signs and symptoms of orthorexia nervosa:[12]
Compulsive checking of ingredients lists and nutritional labels

12.6.2 [Link]
 An increased concern about the health of ingredients
Cutting out an increasing number of food groups such as all sugars, all carbohydrates, all dairy or all animal products
An inability to eat anything but a narrow group of foods that are deemed ‘healthy’ or ‘pure’
Unusual interest in the health of what others are eating
Spending hours per day thinking about what food might be served at upcoming events
Showing high levels of distress when ‘safe’ or ‘healthy’ foods are not available
Obsessive following of food and ‘healthy lifestyle’ blogs on social media
Body image concerns may or may not present

The Healing Process

With all wounds, from a paper cut to major surgery, the body must heal itself. Healing is facilitated through proper nutrition while
malnutrition inhibits and complicates this vital process. The following nutrients are important for proper healing:[13]
Vitamin A. Helps to enable the epithelial tissue (the thin outer layer of the body and the lining that protects your organs) and
bone cells form.
Vitamin C. Helps form collagen, an important protein in many body tissues.
Protein. Facilitates tissue formation.
Fats. Play a key role in the formation and function of cell membranes.
Carbohydrates. Fuel cellular activity, supplying needed energy to support the inflammatory response that promotes healing.

References
1. Prevalence of Underweight among Children and Adolescents: United States, 2003–2006. Centers for Disease Control and
Prevention. [Link] Updated November 6, 2015. Accessed
April 15, 2018. ↵
2. Eating Disorders. The National Institute of Mental Health. [Link]
[Link]#part_155061. Accessed April 15, 2018. ↵
3. Eating Disorders. The National Institute of Mental Health. [Link]
[Link]#part_155061. Accessed April 15, 2018. ↵
4. Eating Disorders. The National Institute of Mental Health. [Link]
[Link]#part_155061. Accessed April 15, 2018. ↵
5. Mathieu J.(2005). What is orthorexia? Journal of the American Dietetic Association, 105(10), 1510-1512. Bratman, S. Health
Food Junkie. Yoga Journal. 1997, September/October, 42-50. Available at [Link]/original-orthorexia-essay/. ↵
6. Donini LM, Marsili D, Graziani MP, Imbriale M, Cannella C. (2004). Orthorexia nervosa: a preliminary study with a proposal
for diagnosis and an attempt to measure the dimension of the phenomenon. Eating and Weight Disorders, 9(2), 151‐157. ↵
7. Mathieu J. (2005). What is orthorexia? Journal of the American Dietetic Association, 105(10), 1510-1512. Bratman, S. Health
Food Junkie. Yoga Journal. 1997, September/October, 42-50. Available at [Link]/original-orthorexia-essay/. ↵
8. Donini LM, Marsili D, Graziani MP, Imbriale M, Cannella C. (2004). Orthorexia nervosa: a preliminary study with a proposal
for diagnosis and an attempt to measure the dimension of the phenomenon. Eating and Weight Disorders, 9(2), 151‐157. ↵
9. Orthorexia. (2017, February 26). National Eating Disorders Association. [Link]
eating-disorder/other/orthorexia↵
10. Mathieu J. (2005). What is orthorexia? Journal of the American Dietetic Association, 105(10), 1510-1512. Bratman, S. Health
Food Junkie. Yoga Journal. 1997, September/October, 42-50. Available at [Link]/original-orthorexia-essay/. ↵
11. Orthorexia. (2017, February 26). National Eating Disorders Association. [Link]
eating-disorder/other/orthorexia ↵
12. Orthorexia. (2017, February 26). National Eating Disorders Association. [Link]
eating-disorder/other/orthorexia ↵
13. MacKay D, Miller AL. (2003). Nutritional Support for Wound Healing. Alternative Medicine Review, 8(4), 359–77.
[Link] Accessed April 15, 2018. ↵

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12.6.3 [Link]
standards of the LibreTexts platform.
18.6: Undernutrition, Overnutrition, and Malnutrition by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed
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12.6.4 [Link]
12.7: Food Insecurity
Addressing Hunger
Government agencies also play an important role in addressing hunger via federal food-assistance programs. The agencies provide
debit cards (formerly distributed in the form of food vouchers or food stamps) to consumers to help them purchase food and they
also provide other forms of aid to low-income adults and families who face hunger and nutritional deficits. This topic will be
discussed in greater detail later in this chapter.
Hunger relates to appetite and is the body’s response to a need for nourishment. Through stomach discomfort or intestinal
rumbling, the body alerts the brain that it requires food. This uneasy sensation is easily addressed with a snack or a full meal.
However, the term “hunger” also relates to a weakened condition that is a consequence of a prolonged lack of food. People who
suffer from this form of hunger typically experience malnourishment, along with poor growth and development.

Hunger
Adequate food intake that meets nutritional requirements is essential to achieve a healthy, productive lifestyle. However, millions
of people in North America, not to mention globally, go hungry and are malnourished each year due to a recurring and involuntary
lack of food. The economic crisis of 2008 caused a dramatic increase in hunger across the United States.[1]
In 2010, 925 million people around the world were classified as hungry. Although this was a decrease from a historic high of more
than one billion people from the previous year, it is still an unbearable number. Every night, millions and millions of people go to
sleep hungry due to a lack of the money or resources needed to acquire an adequate amount of food. This graph shows the division
of hungry people around the globe. A number of terms are used to categorize and classify hunger. Two key terms, food security and
food insecurity, focus on status and affect hunger statistics. Another term, malnutrition, refers to the deficiencies that a hungry
person experiences.

Food Security
Most American households are considered to be food secure, which means they have adequate access to food and consume enough
nutrients to achieve a healthy lifestyle. However, a minority of US households experiences food insecurity at certain points during
the year, which means their access to food is limited due to a lack of money or other resources. This graphic shows the percentage
of food-secure and food-insecure households in the United States during the year 2010.

Food Insecurity
Food insecurity is defined as not having adequate access to food that meets nutritional needs. According to the USDA, about 48.8
million people live in food-insecure households and have reported multiple indications of food access problems. About sixteen
million of those have “very low food security,” which means one or more people in the household were hungry at some point over
the course of a year due to the inability to afford enough food. The difference between low and very low food security is that
members of low insecurity households have reported problems of food access, but have reported only a few instances of reduced
food intake, if any.[2] African American and Hispanic households experience food insecurity at much higher rates than the national
average.[3]
Households with limited resources employ a variety of methods to increase their access to adequate food. Some families purchase
junk food and fast food—cheaper options that are also very unhealthy. Other families who struggle with food security supplement
the groceries they purchase by participating in government assistance programs. They may also obtain food from emergency
providers, such as food banks and soup kitchens in their communities.

Malnutrition
A person living in a food-insecure household may suffer from malnutrition, which results from a failure to meet nutrient
requirements. This can occur as a result of consuming too little food or not enough key nutrients. There are two basic types of
malnutrition. The first is macronutrient deficiency and relates to the lack of adequate protein, which is required for cell growth,
maintenance, and repair. The second type of malnutrition is micronutrient deficiency and relates to inadequate vitamin and mineral

12.7.1 [Link]
intake.[4] Even people who are overweight or obese can suffer from this kind of malnutrition if they eat foods that do not meet all of
their nutritional needs.
Worldwide, three main groups are most at risk of hunger: the rural poor in developing nations who also lack access to electricity
and safe drinking water, the urban poor who live in expanding cities and lack the means to buy food, and victims of earthquakes,
hurricanes, and other natural and man-made catastrophes.[5]
In the United States, there are additional subgroups that are at risk and are more likely than others to face hunger and malnutrition.
They include low-income families and the working poor, who are employed but have incomes below the federal poverty level.
Senior citizens are also a major at-risk group. Many elderly people are frail and isolated, which affects their ability to meet their
dietary requirements. In addition, many also have low incomes, limited resources, and difficulty purchasing or preparing food due
to health issues or poor mobility. As a result, more than six million senior citizens in the United States face the threat of hunger.[6]
One of the groups that struggles with hunger are the millions of homeless people across North America. According to a recent study
by the US Conference of Mayors, the majority of reporting cities saw an increase in the number of homeless families.[7] Hunger
and homelessness often go hand-in-hand as homeless families and adults turn to soup kitchens or food pantries or resort to begging
for food.
Rising hunger rates in the United States particularly affect children. Nearly one out of four children, or 21.6 percent of all American
children, lives in a food-insecure household and spends at least part of the year hungry.[8] Hunger delays their growth and
development and affects their educational progress because it is more difficult for hungry or malnourished students to concentrate
in school. In addition, children who are undernourished are more susceptible to contracting diseases, such as measles and
pneumonia.[9]

Government Programs
The federal government has established a number of programs that work to alleviate hunger and ensure that many low-income
families receive the nutrition they require to live a healthy life. A number of programs were strengthened by the passage of the
Healthy, Hunger-Free Kids Act of 2010. This legislation authorized funding and set the policy for several key core programs that
provide a safety net for food-insecure children across the United States.
The federal poverty level (FPL) is used to determine eligibility for food-assistance programs. This monetary figure is the minimum
amount that a family would need to acquire shelter, food, clothing, and other necessities. It is calculated based on family size and is
adjusted for annual inflation. Although many people who fall below the FPL are unemployed, the working poor can qualify for
food programs and other forms of public assistance if their income is less than a certain percentage of the federal poverty level,
along with other qualifications.

USDA Food Assistance Programs

Government food and nutrition assistance programs that are organized and operated by the USDA work to increase food security.
They provide low-income households with access to food, the tools for consuming a healthy diet, and education about nutrition.
The USDA monitors the extent and severity of food insecurity via an annual survey. This contributes to the efficiency of food
assistance programs as well as the effectiveness of private charities and other initiatives aimed at reducing food insecurity.[10]

The Supplemental Nutrition Assistance Program

Formerly known as the Food Stamp Program, the Supplemental Nutrition Assistance Program (SNAP) provides monthly benefits
for low-income households to purchase approved food items at authorized stores. Clients qualify for the program based on
available household income, assets, and certain basic expenses. In an average month, SNAP provides benefits to more than forty
million people in the United States.[11] The program provides Electronic Benefit Transfers (EBT) which work similarly to a debit
card. Clients receive a card with a certain allocation of money for each month that can be used only for food. In 2010, the average
benefit was about $134 per person, per month and total federal expenditures for the program were $68.2 billion.[12]

The Special, Supplemental Program for Women, Infants, and Children

The Special, Supplemental Program for Women, Infants and Children (WIC) provides food packages to pregnant and breastfeeding
women, as well as to infants and children up to age five, to promote adequate intake for healthy growth and development. Most

12.7.2 [Link]
state WIC programs provide vouchers that participants use to acquire supplemental packages at authorized stores. In 2010, WIC
served approximately 9.2 million participants per month at an average monthly cost of about forty-two dollars per person.[13]

The National School Lunch Program

The National School Lunch Program (NSLP) and School Breakfast Program (SBP) ensure that children in elementary and middle
schools receive at least one healthy meal each school day, or two if both the NSLP and SBP are provided. According to the USDA,
these programs operate in over 101,000 public and nonprofit private schools and residential child-care institutions.[14] In 2010, the
programs provided meals to an average of 31.6 million children each school day. Fifty-six percent of the lunches served were free,
and an additional 10 percent were provided at reduced prices.

Meals on Wheels
An organization known as Meals on Wheels delivers meals to elderly people who have difficulty buying or making their own food
because of poor health or limited mobility. It is the oldest and largest program dedicated to addressing the nutritional needs of
senior citizens. Each day, Meals on Wheels volunteers deliver more than one million meals across the United States. The first
Meals on Wheels program began in Philadelphia in the 1950s. In the decades since, the organization has expanded into a vast
network that serves the elderly in all fifty states and several US territories. Today, Meals on Wheels remains committed to ending
hunger among the senior citizen community.[15]

Nutrition and Your Health

The adage, “you are what you eat,” seems to be more true today than ever. In recent years, consumers have become more
conscientious about the decisions they make in the supermarket. Organically grown food is the fastest growing segment of the food
industry. Also, farmers’ markets and chains that are health-food-oriented are thriving in many parts of North America. Shoppers
have begun to pay more attention to the effect of food on their health and well-being. That includes not only the kinds of foods that
they purchase, but also the manner in which meals are cooked and consumed. The preparation of food can greatly affect its
nutritional value. Also, studies have shown that eating at a table with family members or friends can promote both health and
happiness.

References
1. Hunger in America: 2016 United States Hunger and Poverty Facts. World Hunger Education Service. Retrieved from
[Link]/articles/Learn/us_hunger_facts.htm. Accessed April 15, 2018. ↵
2. Coleman-Jensen A. Household Food Security in the United States in 2010. US Department of Agriculture, Economic Research
Report, no. ERR-125. 2011. [Link] Accessed April 15, 2018. ↵
3. Coleman-Jensen A. Household Food Security in the United States in 2010. US Department of Agriculture, Economic Research
Report, no. ERR-125. 2011. [Link] Accessed April 15, 2018. ↵
4. Hunger in America: 2016 United States Hunger and Poverty Facts. World Hunger Education Service. Retrieved from
[Link]/articles/Learn/us_hunger_facts.htm. Accessed April 15, 2018. ↵
5. SOFI: Questions and Answers. Food and Agriculture Organization of the United Nations. [Link]
Accessed April 15, 208. ↵
6. About Meals on Wheels. Meals on Wheels. [Link] Accessed
April 15, 2018. ↵
7. Hunger and Homelessness Survey: A Status Report on Hunger and Homelessness in America’s Cities, a 27-City Survey. The
United States Conference of Mayors. [Link] Accessed April 15, 2018. ↵
8. Coleman-Jensen A. Household Food Security in the United States in 2010. US Department of Agriculture, Economic Research
Report, no. ERR-125. 2011. [Link] Accessed April 15, 2018. ↵
9. 2011 World Hunger and Poverty Facts and Statistics. World Hunger Education
[Link]/articles/Learn/old/world%20hunger%20facts%[Link]. Accessed April 15, 2018. ↵
10. Coleman-Jensen A. Household Food Security in the United States in 2010. US Department of Agriculture, Economic Research
Report, no. ERR-125. 2011. [Link] Accessed April 15, 2018. ↵
11. Coleman-Jensen A. Household Food Security in the United States in 2010. US Department of Agriculture, Economic Research
Report, no. ERR-125. 2011. [Link] Accessed April 15, 2018. ↵

12.7.3 [Link]
12. Coleman-Jensen A. Household Food Security in the United States in 2010. US Department of Agriculture, Economic Research
Report, no. ERR-125. 2011. [Link] Accessed April 15, 2018. ↵
13. Coleman-Jensen A. Household Food Security in the United States in 2010. US Department of Agriculture, Economic Research
Report, no. ERR-125. 2011. [Link] Accessed April 15, 2018. ↵
14. National School Lunch Program. US Department of Agriculture. [Link]
nslp. Accessed April 15, 2018. ↵
15. The Problem and Our Solution. Meals on Wheels. [Link]
Accessed April 15, 2018. ↵

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12.7.4 [Link]
12.8: Careers in Nutrition
If you are considering a career in nutrition, it is important to understand the opportunities that may be available to you. Both
registered dietitians (RD) and nutritionists provide nutrition-related services to people in the private and public sectors. A RD is a
healthcare professional who has credentials from the Commission on Dietetic Registration and can provide nutritional care in the
areas of health and wellness for both individuals and groups. A nutritionist is an unregistered professional who may have acquired
the knowledge via other avenues. RDs are nutrition professionals who work to apply nutritional science, using evidence-based best
practices, to help people nourish their bodies and improve their lives.
Becoming a RD requires a Bachelor’s or Master’s degree in dietetics from an accredited program, including courses in biology,
chemistry, biochemistry, microbiology, anatomy and physiology, nutrition, and food-service management. Other suggested courses
include economics, business, statistics, computer science, psychology, and sociology. In addition, people who pursue this path must
complete a dietetic internship and pass a national exam. Also, some states have licensure that requires additional forms and
documentation. To become a dietetic technician registered you must complete an undergraduate dietetic program and pass a
national exam. Forty-seven states have licensure requirements for RDs and nutritionists. A few remaining states do not have laws
that regulate this profession.[1] Go to [Link] to learn more.

Working in Nutrition
Registered dietitians (RDs)/registered dietitians nutritionist (RDNs) and nutritionists plan food and nutrition programs, promote
healthy eating habits, and recommend dietary modifications based on the needs of individuals or groups. For example, an RD/RDN
might teach a patient with hypertension how to follow the DASH diet and reduce their sodium intake. Nutrition-related careers can
be extremely varied. Some individuals work in the government, while others are solely in the private sectors (i.e., private practice,
worksite wellness, hospitals, outpatient clinics, etc). Some jobs in nutrition focus on working with elite athletes, while others
provide guidance to patients with long-term, life-threatening diseases. But no matter the circumstance or the clientele, working in
the field of diet and nutrition focuses on helping people improve their dietary habits by translating nutritional science and evidence-
based recommendations into food choices.
In the public sector, careers in nutrition span from government work to community outreach. RDs who work for the government
may become involved with federal food programs, federal agencies, communication campaigns, or creating and analyzing public
policy. On the local level, clinical careers include working in hospitals and nursing-care facilities. This requires creating meal plans
and providing nutritional guidance to help patients restore their health or manage chronic conditions. Clinical dietitians also confer
with doctors and other health-care professionals to coordinate dietary recommendations with medical needs. Nutrition jobs in the
community often involve working in public health clinics, cooperative extension offices, and HMOs to prevent disease and
promote the health of the local community. Nutrition jobs in the nonprofit world involve anti-hunger organizations, public health
organizations, and activist groups.
Nutritionists and dietitians can also find work in the private sector. Increased public awareness of food, diet, and nutrition has led to
employment opportunities in advertising, marketing, and food manufacturing. Dietitians working in these areas analyze foods,
prepare marketing materials, or report on issues such as the impact of vitamins and herbal supplements. Consultant careers can
include working in wellness programs, supermarkets, physicians’ offices, gyms, and weight-loss clinics. Consultants in private
practice perform nutrition screenings for clients and use their findings to provide guidance on diet-related issues, such as weight
reduction. Nutrition careers in the corporate world include designing wellness strategies and nutrition components for companies,
working as representatives for food or supplement companies, designing marketing and educational campaigns, and becoming
lobbyists. Others in the private sector work in food-service management at health-care facilities or at company and school
cafeterias. Sustainable agricultural practices are also providing interesting private sector careers on farms and in food systems.
There are employment opportunities in farm management, marketing and sales, compliance, finance, and land surveying and
appraisal.

Working toward Tomorrow

Whether you pursue nutrition as a career or simply work to improve your own dietary choices, what you have learned in this course
can provide a solid foundation for the future. Remember, your ability to wake up, to think clearly, communicate, hope, dream, go to
school, gain knowledge, and earn a living are totally dependent upon one factor—your health. Good health allows you to function

12.8.1 [Link]
normally and work hard to pursue your goals. Yet, achieving optimal health cannot be underestimated. It is a complex process,
involving multiple dimensions of wellness, along with your physical or medical reality. The knowledge you have now acquired is
also key. However, it is not enough to pass this nutrition class with good grades. Nutrition knowledge must be applied to make a
difference in your life, throughout your life.
Throughout this textbook, we have focused on the different aspects of nutrition science, which helps to optimize health and prevent
disease. Scientific evidence provides the basis for dietary guidelines and recommendations. In addition, researchers in the field of
nutrition work to advance our knowledge of food production and distribution. Nutrition science also examines the ill effects of
malnutrition and food insecurity. The findings that are uncovered today will influence not only what we eat, but how we grow it,
distribute it, prepare it, and even enjoy it tomorrow.

References
1. Dietitians and Nutritionists. Bureau of Labor Statistics. Occupational Outlook Handbook, 2010-11 Edition.
[Link] Updated April 13, 2018. Accessed April 15, 2018. ↵

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12.8.2 [Link]
 CHAPTER OVERVIEW

13: Performance Nutrition

Learning Objectives
By the end of this chapter you will be able to:
Describe the physiological changes that occur in response to exercise
Describe the effects of physical fitness on overall health
Describe the purpose and applications of nutrition supplements

13.1: Introduction to Performance Nutrition

13.2: The Essential Elements of Physical Fitness
13.3: The Benefits of Physical Activity
13.4: Fuel Sources
13.5: Sports Nutrition
13.6: Water and Electrolyte Needs
13.7: Food Supplements and Food Replacements

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platform.

1
13.1: Introduction to Performance Nutrition
He po‘i na kai uli, kai ko‘o, ‘a‘ohe hina pūko‘a
Though the sea be deep and rough, the coral rock remains standing.

Figure : (Unsplash license; Derek Owens via Unsplash)

Becoming and staying physically fit is an important part of achieving optimal health. A well-rounded exercise program is crucial to
becoming and remaining healthy. Physical activity improves your health in a number of ways. It promotes weight loss, strengthens
muscles and bones, keeps the heart and lungs strong, and helps to protect against chronic disease. There are four essential elements
of physical fitness: cardiorespiratory, muscular strength, flexibility, and maintaining a healthful body composition. Some
enthusiasts might argue the relative importance of each, but optimal health requires some degree of balance between all four. For
example, the Hawai‘i Ironman is a vigorous race that consists of a 2.4 mile swim, 112 mile bike, and a 26 mile run. All four
elements of physical fitness are vital in order to complete each leg of the race. To learn more about the Hawai‘i Ironman, visit their
website at [Link]
Some forms of exercise confer multiple benefits, which can help you to balance the different elements of physical fitness. For
example, riding a bicycle for thirty minutes or more not only builds cardiorespiratory endurance, it also improves muscle strength
and muscle endurance. Some forms of yoga can also build muscle strength and endurance, along with flexibility. However,
addressing fitness standards in all four categories generally requires incorporating a range of activities into your regular routine. If
you exercise regularly, your body will begin to change and you will notice that you are able to continue your activity longer. This is
due to the overload principle that our bodies will adapt to with continuous repetition. For example, if you run a mile everyday for a
week, in a few weeks you would be able to run further and likely faster.

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13.1.1 [Link]
13.2: The Essential Elements of Physical Fitness
Cardiorespiratory Endurance
Cardiorespiratory endurance is enhanced by aerobic training which involves activities that increase your heart rate and breathing
such as walking, jogging, or biking. Building cardiorespiratory endurance through aerobic exercise is an excellent way to maintain
a healthy weight. Working on this element of physical fitness also improves your circulatory system. It boosts your ability to supply
the body’s cells with oxygen and nutrients, and to remove carbon dioxide and metabolic waste. Aerobic exercise is continuous
exercise (lasting more than 2 minutes) that can range from low to high levels of intensity. In addition, aerobic exercise increases
heart and breathing rates to meet increased demands for oxygen in working muscles. Regular, moderate aerobic activity, about
thirty minutes at a time for five days per week, trains the body to deliver oxygen more efficiently, which strengthens the heart and
lungs, and reduces the risk of cardiovascular disease.[1] Strengthening your heart muscle and increasing the blood volume pumped
each heartbeat will lead to a lower resting heart rate for healthy individuals. Aerobic exercise increases the ability of muscles to use
oxygen for energy metabolism therefore creating ATP.
Aerobic capacity, or VO2 is the most common standard for evaluating cardiorespiratory endurance. VO2 max is your maximal
oxygen uptake, and the VO2 max test measures the amount of oxygen (in relation to body weight) that you can use per minute. A
test subject usually walks or runs on a treadmill or rides a stationary bicycle while the volume and oxygen content of exhaled air is
measured to determine oxygen consumption as exercise intensity increases. At some point, the amount of oxygen consumed no
longer increases despite an increase in exercise intensity. This value of oxygen consumption is referred to as VO2 max, ‘V’
meaning volume, and ‘max’ meaning the maximum amount of oxygen ( ) an individual is capable of utilizing. The higher the
number, the more oxygen you can consume, and the faster or longer you can walk, run, bike, or swim, among other aerobic
activities. VO2 max can increase over time with training.[2]

Figure : VO2 Max Test. Image by Cosmed / CC BY-SA 3.0

Muscle Strength
Muscle strength is developed and maintained by weight or resistance training that often is called anaerobic exercise. Anaerobic
exercise consists of short duration, high intensity movements that rely on immediately available energy sources and require little or
no oxygen during the activity. This type of high intensity training is used to build muscle strength by short, high intensity activities.
Building muscle mass is not just crucial for athletes and bodybuilders—building muscle strength and endurance is important for
children, seniors, and everyone in between. The support that your muscles provide allows you to work, play, and live more
efficiently. Strength training involves the use of resistance machines, resistance bands, free weights, or other tools. However, you
do not need to pay for a gym membership or expensive equipment to strengthen your muscles. Homemade weights, such as plastic
bottles filled with sand, can work just as well. You can also use your own body weight and do push-ups, leg squats, abdominal
crunches, and other exercises to build your muscles. If strength training is performed at least twice a week, it can help to improve
muscle strength and to increase bone strength. Strength training can also help you to maintain muscle mass during a weight-loss
program.[3]

13.2.1 [Link]
Flexibility
Flexibility is the range of motion available to your joints. Yoga, tai chi, Pilates, and stretching exercises work to improve this
element of fitness. Stretching not only improves your range of motion, it also promotes better posture, and helps you perform
activities that can require greater flexibility, such as chores around the house. In addition to working on flexibility, older adults
should include balance exercises in their regular routine. Balance tends to deteriorate with age, which can result in falls and
fractures.[4]

Body Composition
Body composition is the proportion of fat and fat-free mass (which includes bones, muscles and organs) in your body. A healthy
and physically fit individual has a greater proportion of muscle and smaller proportion of fat than an unfit individual of the same
weight. Although habitual physical activity can promote a more healthful body composition, other factors like age, gender,
genetics, and diet contribute to an individual’s body composition. Women have a higher healthy fat percentage than men. For adult
women, a healthy amount of body fat ranges from 20 to 32 percent. Adult males on the other hand range from 10 to 22 percent of
body fat.[5]

Metabolic Fitness
Being fit also includes metabolic fitness. It relates to the number of calories you require to survive and the number of calories you
burn during physical activity. Recall that metabolism is the sum of all chemical reactions that occur in the human body to conduct
life’s processes. Some are catabolic reactions that break down nutrients to supply the body with cellular energy. The rate at which a
person burns calories depends on body composition, gender, age, nutritional status, physical activity, and genetics.
Increasing your daily activity and shedding excess body fat helps to improve metabolic fitness. Physical activity also makes weight
management easier because it increases energy needs and lean body mass. During moderate to vigorous activity, energy
expenditure raises well above the resting rate. With continuous exercise over time, regular exercise increases lean body mass as
well. At rest, lean tissues use more energy than fat tissue therefore increasing basal metabolism. The combination of increased
energy output, energy expenditure and basal needs over a long period of time can have a major impact on total energy expenditure
(see Figure 16.2). The more energy you expend, the more foods you are able to consume while maintaining a healthy weight. Any
improvement to metabolic fitness is beneficial and means a decrease in the risk for developing diabetes, or other chronic
conditions.
One measurement of metabolic fitness is basal metabolic rate, or BMR, which is a measurement of the amount of energy required
for the body to maintain its basic functions while at rest, i.e. breathing, heart beats, liver and kidney function, and so on. On
average, BMR accounts for between 50 and 70 percent of a person’s total daily energy expenditure. Different factors can affect the
BMR. For example, a slender person who is tall has more body surface area and therefore has a higher RMR relative to their body
mass (weight). Also, muscle utilizes more energy at rest than fat, so a person with more muscle mass has a higher BMR.
A second measurement of metabolic fitness is the number of calories burned during physical activity. The amount of calories
burned depends on how much oxygen is delivered to tissues, and how efficiently metabolic reactions consume oxygen and,
therefore, expend calories. One of the best estimates of energy expenditure during exercise is how much oxygen a person
consumes. Recall that VO2 max is a measure of the maximum cardiorespiratory capacity to deliver oxygen to the body, especially
to working muscles during exercise.. Greater VO2 max is indicative of better cardiovascular fitness. In contrast to RMR, VO2 max
increases significantly with exercise training due to training adaptations that increase the body’s ability to deliver oxygen to
working tissues and an increased capacity of muscles to take up and utilize oxygen.

13.2.2 [Link]
 Figure Figure : The Effect of Physical Activity on Energy
Expenditure. Image by Allison Calabrese / CC BY 4.0

Physical Activity Recommendations

The CDC along with the American College of Sports Medicine (ACSM) have evidence based recommendations and guidelines for
individuals to follow in order to obtain or maintain a healthy lifestyle. Adults should get at least 150 minutes of moderate-intensity
aerobic physical activity or 75 minutes of vigorous-intensity aerobic physical activity each week. In addition to aerobic physical
activity, it is recommended that adults do muscle strengthening activities on each major muscle group two or three times each
week. Adults also are recommended by the ACSM to do flexibility exercises at least two to three times a week to improve range of
motion. To learn more about these guidelines visit the CDC website at [Link] and
the ACSM website at [Link]
on-quantity-and-quality-of-exercise.

Learning Activities
References
1. The American Heart Association Recommendations for Physical Activity in Adults. American Heart Association. [Link].
[Link]/HEARTORG/HealthyLiving/PhysicalActivity/FitnessBasics/American-Heart-Association-Recommendations-
for-Physical-Activity-Infographic_UCM_450754_SubHomePage.jsp. Accessed March 10, 2018. ↵
2. Ed Eyestone. How to Improve Your VO2 Max. [Link]. [Link]
-12408-0,[Link]. Published January 9, 2008. ↵
3. American College of Sports Medicine. Resistance Training for Health and Fitness. [Link].
[Link]/docs/brochures/[Link]. Accessed March 11, 2018. ↵
4. Fitness Training: Elements of a Well-Rounded Routine. [Link]. [Link]/health/fitness-
training/HQ01305. Updated August 10, 2017. ↵
5. Measuring and Evaluating Body Composition. [Link]. [Link]
information/articles/2016/10/07/measuring-and-evaluating-body-composition↵

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13.2.3 [Link]
13.3: The Benefits of Physical Activity
Regular physical activity is one of the best things you can do to achieve optimal health. Individuals who are physically active for
about seven hours per week lower the risk of dying early by 40 percent compared to those who are active for less than thirty
minutes per week.[1] Improving your overall fitness involves sticking with an exercise program on a regular basis. If you are
nervous or unsure about becoming more active, the good news is that moderate-intensity activity, such as brisk walking, is safe for
most people. Also, the health advantages of becoming active far outweigh the risks. Physical activity not only helps to maintain
your weight, it also provides a wealth of benefits—physical, mental, and emotional.

Physical Benefits
Getting the recommended amount of physical activity each week, about 150 minutes of moderate, aerobic exercise, such as power
walking or bicycling, does not require joining a gym, or taking expensive, complicated classes. If you can’t commit to a formal
workout four to five days per week, you can become more active in simple ways—by taking the stairs instead of the elevator, by
walking more instead of driving, by going out dancing with your friends, or by doing your household chores at a faster pace. It is
not necessary to perform at the level of a professional dancer or athlete, or to work out for several hours every day, to see real gains
from exercise. Even slightly increased activity can lead to physical benefits, such as:
Longer life. A regular exercise program can reduce your risk of dying early from heart disease, certain cancers, and other
leading causes of death.
Healthier weight. Exercise, along with a healthy, balanced eating plan, can help you lose extra weight, maintain weight loss, or
prevent excessive weight gain.
Cardiovascular disease prevention. Being active boosts HDL cholesterol and decreases unhealthy triglycerides, which reduces
the risk of cardiovascular diseases.
Management of chronic conditions. A regular routine can help to prevent or manage a wide range of conditions and concerns,
such as metabolic syndrome, type 2 diabetes, depression, arthritis, and certain types of cancer.
Energy boosts. Regular physical activity can improve muscle tone and strength and provide a boost to your cardiovascular
system. When the heart and lungs work more efficiently, you have more energy.
Strong bones. Research shows that aerobic activity and strength training can slow the loss of bone density that typically
accompanies aging.

Mental and Emotional Benefits

The benefits of an exercise program are not just physical, they are mental and emotional as well. Anyone who has gone for a walk
to clear their head knows the mental benefits of exercise firsthand. Also, you do not have to be a marathoner on a “runner’s high” to
enjoy the emotional benefits of becoming active. The mental and emotional benefits of physical activity include:
Mood improvement. Aerobic activity, strength-training, and more contemplative activities such as yoga, all help break cycles of
worry, absorption, and distraction, effectively draining tension from the body.
Reduced risk of depression, or limited symptoms of it. Some people have called exercise “nature’s antidepressant,” and studies
have shown that physical activity reduces the risk of and helps people cope with the symptoms of depression.
Cognitive skills retention. Regular physical activity can help people maintain thinking, learning, and judgement as they age.
Better sleep. A good night’s sleep is essential for clear thinking, and regular exercise promotes healthy, sound sleep. It can also
help you fall asleep faster and deepen your rest.

Changing to a More Active Lifestyle

A physically active lifestyle yields so many health benefits that it is recommended for everyone. Change is not always easy, but
even small changes such as taking the stairs instead of the elevator, or parking farther away from a store to add a bit more walking
into your day can lead to a more active lifestyle and set you on the road to optimal health. When people go one step further by
walking or biking on a regular basis, or becoming active by growing and maintaining a garden, they do more than promote their
own health—they safeguard the health of the planet, too.

13.3.1 [Link]
As you change to a more active lifestyle, select an activity that you can integrate into your schedule smoothly, so you can maintain
it. For example, instead of making time to get coffee with friends, you might suggest a walk, rollerblading, or going for a swim in
the campus pool. Also, find an activity that you will be motivated to do. Some people decide to participate in team sports, such as
local soccer or softball leagues, because they enjoy being active with others or like knowing that a team relies on them. Others
prefer to take a class, such as spinning or yoga, that is led by an instructor who will motivate them. Still others prefer more solitary
pursuits, such as taking a jog alone in their neighborhood. No matter what your preference, you are more likely to stick to a
workout program if you enjoy it.

References
1. Physical Activity and Health: The Benefits of Physical Activity. [Link].
[Link] Last updated February 16, 2011. ↵

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Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
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4.0. Original source: [Link]

13.3.2 [Link]
13.4: Fuel Sources
The human body uses carbohydrate, fat and protein in food and from body stores as energy. These essential nutrients are needed
regardless of the intensity of activity you are doing. If you are lying down reading a book or running the the Honolulu Marathon,
these macronutrients are always needed in the body. However, in order for these nutrients to be used as fuel for the body, their
energy must be transferred into the high energy molecule known as Adenosine Triphosphate (ATP). ATP is the body’s immediate
fuel source of energy that can be generated either with the presences of oxygen known as aerobic metabolism or without the
presence of oxygen by anaerobic metabolism. The type of metabolism that is predominately used during physical activity is
determined by the availability of oxygen and how much carbohydrate, fat, and protein are used.

Anaerobic and Aerobic Metabolism

Anaerobic metabolism occurs in the cytosol of the muscle cells. As seen in Figure 16.2, a small amount of ATP is produced in the
cytosol without the presence of oxygen. Anaerobic metabolism uses glucose as its only source of fuel and produces pyruvate and
lactic acid. Pyruvate can then be used as fuel for aerobic metabolism. Aerobic metabolism takes place in the mitochondria of the
cell and is able to use carbohydrates, protein or fat as its fuel source. Aerobic metabolism is a much slower process than anaerobic
metabolism but produces majority of the ATP.

Figure Figure : Anaerobic versus

Aerobic Metabolism. Image by Allison Calabrese / CC BY 4.0

Physical Activity Duration and Fuel Use

The respiratory system plays a vital role in the uptake and delivery of oxygen to muscle cells throughout the body. Oxygen is
inhaled by the lungs and transferred from the lungs to the blood where the cardiovascular system circulates the oxygen-rich blood
to the muscles. The oxygen is then taken up by the muscles and can be used to generate ATP. When the body is at rest, the heart and
lungs are able to supply the muscles with adequate amounts of oxygen to meet the aerobic metabolism energy needs. However,
during physical activity your muscles energy and oxygen needs are increased. In order to provide more oxygen to the muscle cells,
your heart rate and breathing rate will increase. The amount of oxygen that is delivered to the tissues via the cardiovascular and
respiratory systems during exercise depend on the duration, intensity and physical conditioning of the individual.
During the first few steps of exercise, your muscles are the first to respond to the change in activity level. Your lungs and heart
however do not react as quickly and during those beginning steps they do not begin to increase the delivery of oxygen. In order for
our bodies to get the energy that is needed in these beginning steps, the muscles rely on a small amount of ATP that is stored in
resting muscles. The stored ATP is able to provide energy for only a few seconds before it is depleted. Once the stored ATP is just

13.4.1 [Link]
about used up, the body resorts to another high-energy molecule known as creatine phosphate to convert ADP (adenosine
diphosphate) to ATP. After about 10 seconds, the stored creatine phosphate in the muscle cells are also depleted as well.
About 15 seconds into exercise, the stored ATP and creatine phosphate are used up in the muscles. The heart and lungs have still
not adapted to the increase need of oxygen so the muscles must begin to produce ATP by anaerobic metabolism (without oxygen).
Anaerobic metabolism can produce ATP at a rapid pace but only uses glucose as its fuel source. The glucose is obtained from the
blood of muscle glycogen. At around 30 seconds, anaerobic pathways are operating at their full capacity but because the
availability of glucose is limited, it cannot continue for a long period of time.
As your exercise reaches two to three minutes, your heart rate and breathing rate have increased to supply more oxygen to your
muscles. Aerobic metabolism is the most efficient way of producing ATP by producing 18 times more ATP for each molecule of
glucose than anaerobic metabolism. Although the primary source of ATP in aerobic metabolism is carbohydrates, fatty acids and
protein can also be used as fuel to generate ATP.

Figure : The Effect of Exercise Duration on Energy

Systems. Image by Allison Calabrese / CC BY 4.0
The fuel sources for anaerobic and aerobic metabolism will change depending on the amount of nutrients available and the type of
metabolism. Glucose may come from blood glucose (which is from dietary carbohydrates or liver glycogen and glucose synthesis)
or muscle glycogen. Glucose is the primary energy source for both anaerobic and aerobic metabolism. Fatty acids are stored as
triglycerides in muscles but about 90% of stored energy is found in adipose tissue. As low to moderate intensity exercise continues
using aerobic metabolism, fatty acids become the predominant fuel source for the exercising muscles. Although protein is not
considered a major energy source, small amounts of amino acids are used while resting or doing an activity. The amount of amino
acids used for energy metabolism increase if the total energy intake from your diet does not meet the nutrient needs or if you are
involved in long endurance exercises. When amino acids are broken down removing the nitrogen-containing amino acid, that
remaining carbon molecule can be broken down into ATP via aerobic metabolism or used to make glucose. When exercise
continues for many hours, amino acid use will increase as an energy source and for glucose synthesis.

13.4.2 [Link]
 Figure : Fuel Sources for Anaerobic and
Aerobic Metabolism. Image by Allison Calabrese / CC BY 4.0

Physical Activity Intensity and Fuel Use

The exercise intensity determines the contribution of the type of fuel source used for ATP production(see Figure 16.4). Both
anaerobic and aerobic metabolism combine during exercise to ensure that the muscles are equipped with enough ATP to carry out
the demands placed on them. The amount of contribution from each type of metabolism will depend on the intensity of an activity.
When low-intensity activities are performed, aerobic metabolism is used to supply enough ATP to muscles. However, during high-
intensity activities more ATP is needed so the muscles must rely on both anaerobic and aerobic metabolism to meet the body’s
demands.
During low-intensity activities, the body will use aerobic metabolism over anaerobic metabolism because it is more efficient by
producing larger amounts of ATP. Fatty acids are the primary energy source during low-intensity activity. With fat reserves in the
body being almost unlimited, low-intensity activities are able to continue for a long time. Along with fatty acids, a small amount of
glucose is used as well. Glucose differs from fatty acids where glycogen storages can be depleted. As glycogen stores are depleted,
fatigue will eventually set in.

Figure Figure : The Effect of Exercise Intensity on Fuel

Sources. Image by Allison Calabrese / CC BY 4.0

13.4.3 [Link]
  The Fat-Burning Zone

The fat-burning zone is a low intensity aerobic activity that keeps your heart rate between 60 and 69% of your maximum heart
rate. The cardio zone on the other hand is a high intensity aerobic activity that keeps the heart rate between about 70 to 85% of
your maximum heart rate. So which zone do you burn the most fat in? Technically, your body burns a higher percentage of of
calories from fat during a low intensity aerobic activity but there’s more to it than just that. When you begin a low intensity
activity, about 50% of the calories burned comes from fat whereas in the cardio zone only 40% come from fat. However, when
looking at the actual numbers of calories burned, higher intensity activity burns just as much fat and a much greater total
calories overall.

Figure : Image by Allison Calabrese / CC BY 4.0

“Hitting the Wall” or “Bonking”

If you are familiar with endurance sports, you may have heard of “hitting the wall” or “bonking.” These colloquial terms refer to
the extreme fatigue that sets in after about 120 minutes of performing an endurance sport, such as marathon running or long-
distance cycling. The physiology underlying “hitting the wall” means that muscles have used up all their stored glycogen and are
therefore dependent on other nutrients to support their energy needs. Fatty acids are transported from fat-storing cells to the muscle
to rectify the nutrient deficit. However, fatty acids take more time to convert to energy than glucose, thus decreasing performance
levels. To avoid “hitting the wall” or “bonking,” endurance athletes load up on carbohydrates for a few days before the event,
known as carbohydrate loading. This will maximize an athlete’s amount of glycogen stored in their liver and muscle tissues. It is
important not to assume that carbohydrate loading works for everyone. Without accompanied endurance training you will not
increase the amount of stored glucose. If you plan on running a five-mile race for fun with your friend and decide to eat a large
amount of carbohydrates in the form of a big spaghetti dinner the night before, the excess carbohydrates will be stored as fat.
Therefore, if you are not an endurance athlete exercising for more than 90 minutes, carbohydrate loading will provide no benefit,
and can even have some disadvantages. Another way for athletes to avoid “hitting the wall” is to consume carbohydrate-containing
drinks and foods during an endurance event. In fact, throughout the Tour de France—a twenty-two-day, twenty-four-hundred-mile
race—the average cyclist consumes greater than 60 grams of carbohydrates per hour.

Learning Activities

This page titled 13.4: Fuel Sources is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper,
Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.
16.4: Fuel Sources by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original source:
[Link]

13.4.4 [Link]
13.5: Sports Nutrition
Nutrient Needs for Athletes
Nutrition is essential to your performance during all types of exercise. The foods consumed in your diet are used to provide the
body with enough energy to fuel an activity regardless of the intensity of activity. Athletes have different nutritional needs to
support the vigorous level they compete and practice at.

Energy Needs
To determine an athletes nutritional needs, it is important to revisit the concept of energy metabolism. Energy intake is the
foundation of an athlete’s diet because it supports optimal body functions, determines the amount of intake of macronutrients and
micronutrients, and assists in the maintaining of body composition. Energy needs for athletes increase depending on their energy
expenditure. The energy expended during physical activity are contingent on the intensity, duration, and frequency of the exercise.
Competitive athletes may need 3,000 to over 5,000 calories daily compared to a typical inactive individual who needs about 2,000
calories per day. Energy needs are also affected by an individual’s gender, age, and weight. Weight-bearing exercises, such as
running, burn more calories per hour than non-weight bearing exercises, such as swimming. Weight-bearing exercises requires your
body to move against gravity which requires more energy. Men are also able to burn more calories than women for the same
activity because they have more muscle mass which requires more energy to support and move around.[1]
Body weight and composition can have a tremendous impact on exercise performance. Body weight and composition are
considered the focal points of physique for athletes because they are the able to be manipulated the most. Energy intake can play a
role in manipulating the physiques for athletes. For individuals competing in sports such as football and weight lifting, having a
large amount of muscle mass and increased body weight may be beneficial. This can be obtained through a combination of
increased energy intake, and protein. Although certain physiques are more advantageous for specific sports, it is important to
remember that a single and rigid “optimal” body composition is not recommended for any group of athletes.[2]

Macronutrient Needs
The composition of macronutrients in the diet is a key factor in maximizing performance for athletes. Carbohydrates are an
important fuel source for the brain and muscle during exercise. Carbohydrate storage in the liver and muscle cells are relatively
limited and therefore it is important for athletes to consume enough carbohydrates from their diet. Carbohydrate needs should
increase about 3-10 g/kg/day depending on the type of training or competition.[3] See Table for carbohydrate needs for
athletes depending on the intensity of the exercise.
Table : Daily Needs for Carbohydrate Fuel

Increase of Carbohydrate (g/kg of athlete’s

Activity Level Example of Exercise
body weight/day)

Light Low intensity or skill based activities 3-5

Moderate exercise program (about 1 hour

Moderate 5-7
per day)

Endurance program (about 1-3 hours per

High 6-10
day of moderate to high intensity exercise)

Extreme commitment (4-5 hours per day of

Very High 8-12
moderate to high intensity exercise)

Source: Nutrition and Athletic Performance. American College of Sports [Link] & Science in Sports & Exercise.
2016; 48(3), 543- 568. [Link]/acsm-msse/Fulltext/2016/03000/Nutrition_and_Athletic_Performance.[Link]. Accessed
March 17, 2018.
Fat is a necessary component of a healthy diet to provide energy, essential fatty acids and to facilitate the absorption of fat-soluble
vitamins. Athletes are recommended to consume the same amount of fat in the diet as the general population, 20-35% of their

13.5.1 [Link]
energy intake. Although these recommendations are in accordance with public health guidelines, athletes should individualize their
needs based on their training level and body composition goals. Athletes who choose to excessively restrict their fat intake in an
effort to lose body weight or improve body composition should ensure they are still getting the minimum recommended amount of
fat. Fat intakes below 20% of energy intake will reduce the intake of fat-soluble vitamins and essential fatty acids, especially
omega 3’s. [4]
Although protein accounts for only about 5% of energy expended, dietary protein is necessary to support metabolic reactions (that
generate ATP), and to help muscles with maintenance, growth, and repair. During exercise, these metabolic reactions for generating
ATP rely heavily on proteins such as enzymes and transport proteins. It is recommended that athletes consume 1.2 to 2.0 g/kg/day
of proteins in order to support these functions. Higher intakes may also be needed for short periods of intense training or when
reducing energy intake.[5] See Table below for a better representation of protein needs depending on extent of training and
dietary sources.
Table : The Recommended Protein Intakes for Individuals
Group Protein Intake (g/kg body weight)

Most adults 0.8

Endurance athletes 1.2 to 1.4

Vegetarian endurance athletes 1.3 to 1.5

Strength athletes 1.6 to 1.7

Vegetarian strength athletes 1.7 to 1.8

Source: Dietary Reference Intakes, 2002 ACSM/ADA/Dietitians of Canada Position Statement: Nutrition & Athletic Performance,
2001. Accessed March 17, 2018.
It is important to consume adequate amounts of protein and to understand that the quality of the protein consumed affects the
amount needed. High protein foods such as meats, dairy, and eggs contain all of the essential amino acids in relative amounts that
most efficiently meet the body’s needs for growth, maintenance and repair of muscles. Vegetarian diets contain protein that has
lower digestibility and amino acid patterns that do not match human needs as closely as most animal proteins. To compensate for
this as well as the fact that plant food protein sources also contain higher amounts of fiber, higher protein intakes are recommended
for vegetarian athletes. (See Table 16.2 )

Micronutrient Needs
Vitamins and minerals are essential for energy metabolism, the delivery of oxygen, protection against oxidative damage, and the
repair of body structures. When exercise increases, the amount of many vitamins and minerals needed are also increased due to the
excess loss in nutrients. Currently, there is not special micronutrient recommendations made for athletes but most athletes will meet
their needs by consuming a balanced diet that meets their energy needs. Because the energy needs of athletes increase, they often
consume extra vitamins and minerals. The major micronutrients of concern for athletes include iron, calcium, vitamin D, and some
antioxidants. [6]

Common Nutrient Deficiencies for Athletes

Energy deficiency
For athletes, consuming sufficient amounts of calories to support their energy expenditure is vital to maintain health and body
functions. When the energy intake for athletes does not meet the high demands of exercise, a syndrome referred to as relative
deficiency in sport (RED-S) occurs. RED-S has a negative effect on performance and health in both male and female athletes as
shown in Table 16.7. Athletes in sports with weight classes, such as wrestling, may put their health at risk by rapid weight loss in
order to hit a specific weight for a match. These athletes are vulnerable to eating disorders due to sporadic dieting (several of which
will restrict energy intake). The long term effects of these practices can not only impair performance but also have serious
repercussions such as heart and kidney function, temperature regulation and electrolyte balance problems.

13.5.2 [Link]
 Figure : Relative Energy Deficiency in Sport Effects.
Image by Allison Calabrese / CC BY 4.0
Of the RED-S consequences that occur from an energy intake deficiency, the two health effects that are of the greatest concern to
female athletes are menstrual dysfunction and decreased bone density. Menstrual dysfunction and low bone density symptoms of
RED-S can create hormonal imbalances that are described in “Figure 16.8 The Female Athlete Triad”. In today’s society, there is
increasing pressure to be extremely thin that some females take exercise too far. The low energy intakes will lead to the female
athlete triad that causes bone loss, stoppage of menstrual periods, and eating disorders.[7]

Figure : The Female Athlete Triad. Image by

Allison Calabrese / CC BY 4.0

Iron
Iron deficiency is very common in athletes. During exercise, iron-containing proteins like hemoglobin and myoglobin are needed in
great amounts. An iron deficiency can impair muscle function to limit work capacity leading to compromised training performance.
Some athletes in intense training may have an increase in iron losses through sweat, urine, and feces. Iron losses are greater in
females than males due to the iron lost in blood every menstrual cycle. Female athletes, distance runners and vegetarians are at the
greatest risk for developing iron deficiency.[8] See Table Table for the potential amounts of iron loss each day in male and
female athletes. An increased recommendation for both genders are shown below. These recommendations are based on the

13.5.3 [Link]
assumption that iron has a 10% absorption efficiency. As noted above, women athletes have a greater iron loss due to menstruation
and therefore must increase their dietary needs more than male athletes.
Table : The Potential Iron Loss in Endurance Athletes. Approximate Daily Iron Losses in Endurance Athletes (mg/day)and Increased Dietary
Need

Male Female

Sedentary 1 1.5

Athlete 1.8 2.5

*Increase dietary needs 8 10

*Assumes 10% absorption efficiency

Source: Weaver CM, Rajaram [Link] and iron status. J Nutr. 1992 Mar;122(3 Suppl):782-7.
[Link] Accessed March 23, 2018.
Sports anemia, which is different from iron deficiency anemia is an adaptation to training for athletes. Excessive training causes the
blood volume to expand in order to increase the amount of oxygen delivered to the muscles. During sports anemia, the synthesis of
red blood cells lags behind the increase in blood volume which results in a decreased percentage of blood volume that is red blood
cells. The total amount of red blood cells remains the same or may increase slightly to continue the transport of oxygen. Eventually
as training progresses, the amount of red blood cells will increase to catch up with the total blood volume.

Vitamin D and Calcium

Vitamin D regulates the calcium and phosphorus absorption and metabolism and plays a key role in maintaining optimal bone
health. There is also growing evidence that vitamin D is important for other aspect of athletic performance such as injury
prevention, rehabilitation, and muscle metabolism. Individuals who primarily practice indoors are at a larger risk for a vitamin D
deficiency and should ensure they are consuming foods high in vitamin D to maintain sufficient vitamin D status.[9]
Calcium is especially important for the growth, maintenance, and repair of bone tissue. Low calcium intake occurs in athletes with
RED-S, menstrual dysfunction, and those who avoid dairy products. A diet inadequate in calcium increases the risk for low bone
mineral density which ultimately leads to stress fractures.

Antioxidant nutrients
Antioxidant nutrients play an important role in protecting cell membranes from oxidative damage. During exercise, the amount of
oxygen used by the muscles increases and can produce free radicals which causes an increase in antioxidant systems in the the
body. These antioxidant systems rely on the dietary antioxidants such as beta-carotene, vitamin C, vitamin E, and selenium that can
be obtained through a nutrient dense diet.

Learning Activities
1. Nutrition and Athletic Performance. (2016). American College of Sports Medicine. Medicine & Science in Sports & Exercise,
48(3), 543- 568. [Link]/acsm-msse/F...[Link]. Accessed March 17, 2018. ↵
2. Nutrition and Athletic Performance. (2016). American College of Sports Medicine. Medicine & Science in Sports & Exercise,
48(3), 543- 568. [Link]/acsm-msse/F...[Link]. Accessed March 17, 2018. ↵
3. Nutrition and Athletic Performance. (2016). American College of Sports Medicine. Medicine & Science in Sports & Exercise,
48(3), 543- 568. [Link]/acsm-msse/F...[Link]. Accessed March 17, 2018. ↵
4. Nutrition and Athletic Performance. (2016), American College of Sports Medicine. Medicine & Science in Sports & Exercise,
48(3), 543- 568. [Link]/acsm-msse/F...[Link]. Accessed March 17, 2018. ↵
5. Nutrition and Athletic Performance. (2016). American College of Sports Medicine. Medicine & Science in Sports & Exercise,
48(3), 543- 568. [Link]/acsm-msse/F...[Link]. Accessed March 17, 2018. ↵
6. Nutrition and Athletic Performance. (2016). American College of Sports Medicine. Medicine & Science in Sports & Exercise,
48(3), 543- 568. [Link]/acsm-msse/F...[Link]. Accessed March 17, 2018. ↵

13.5.4 [Link]
 7. The Female Athlete Triad. (2016). American College of Sports Medicine. [Link]
information/articles/2016/10/07/the-female-athlete-triad. Published October 7, 2016. Accessed March 16, 2018. ↵
8. Beard J, Tobin B. (2000). Iron Status and Exercise. The American Journal of Clinical Nutrition, 72(2), 594S–597S.
[Link]/ajcn/article/72/2/594S/4729672. Accessed March 16, 2018. ↵
9. Nutrition and Athletic Performance. (2016). American College of Sports Medicine. Medicine & Science in Sports & Exercise,
48(3), 543- 568. [Link]/acsm-msse/F...[Link]. Accessed March 17, 2018. ↵

This page titled 13.5: Sports Nutrition is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper,
Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.
16.5: Sports Nutrition by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original
source: [Link]

13.5.5 [Link]
13.6: Water and Electrolyte Needs
During exercise, being appropriately hydrated contributes to performance. Water is needed to cool the body, transport oxygen and
nutrients, and remove waste products from the muscles. Water needs are increased during exercise due to the extra water losses
through evaporation and sweat. Dehydration can occur when there is inadequate water levels in the body and can be very hazardous
to the health of an individual. As the severity of dehydration increases, the exercise performance of an individual will begin to
decline (see Figure ). It is important to continue to consume water before, during and after exercise to avoid dehydration as
much as possible.

Figure : Dehydration Effect on Exercise

Performance. Image by Allison Calabrese / CC BY 4.0
During exercise, thirst is not a reliable short term indicator of the body’s needs as it typically is not enough to replace the water
loss. Even with the constant replenishing of water throughout an exercise, it may not be possible to drink enough water to
compensate for the losses. Dehydration occurs when the total loss of water is so significant that the total blood volume decreases
which leads to the reduction of oxygen and nutrients transported to the muscle cells. A decreased blood volume also reduces the
blood flow to the skin and the production of sweat which can increase the body temperature. As a result, the risk of heat related
illnesses increases.
Heat cramps are one of the heat related illnesses that can occur during or after exercise. Heat cramps are involuntary muscle spasms
that usually involve the muscle being exercised, which causes by an imbalance of electrolytes, usually sodium. Heat exhaustion is
caused the the loss of water decreasing the blood volume so much that it is not possible to cool the body as well as provide oxygen
and nutrients to the active muscles. Symptoms that arise from heat exhaustion may include low blood pressure, disorientation,
profuse sweating, and fainting. Heat exhaustion can progress further if exercise continues into a heat stroke. A heat stroke is the
most serious form of heat related illnesses that can occur. During a heat stroke, the internal body temperature rises above 105℉
which causes the brain’s temperature-regulatory center to shut down. When the brain’s temperature regulatory center shuts down,
an individual is unable to sweat regardless of their internal body temperature rising. Other symptoms that arise are dry skin,
extreme confusion, and unconsciousness. A heat stroke requires immediate medical attention.
The external temperature during exercise can also play a role in the risk of heat related illnesses. As the external temperature
increases, it becomes more difficult for the body to dissipate heat. As humidity also increases, the body is unable to cool itself
through evaporation. The Heat Index is a measure of how hot the body feels when humidity is added to the air temperature (see
Figure ).

13.6.1 [Link]
 Figure : The Heat Index. “Heat Index” by National Weather
Service, Southern Region Headquarters / Public Domain

Hyponatremia
Sweating during exercise helps our bodies to stay cool. Sweat consists of mostly water but it also causes losses of sodium,
potassium, calcium and magnesium. During most exercises, the amount of sodium lost is very [Link] water after
completing an exercise will replenish the sodium in the body. However, during long endurance exercises such as a marathon or
triathlon, sodium losses are larger and must be replenished as well. If water is replenished without sodium the sodium already in
the body will become diluted. These low levels of sodium in the blood will cause a condition known as hyponatremia (see Figure
). When sodium levels in the blood are decreased, water moves into the cell through osmosis which causes swelling.
Accumulation of fluid in the lungs and the brain can cause serious life threatening conditions such as a seizure, coma and death.
In order to avoid hyponatremia, athletes should increase their consumption of sodium in the days leading up to an event and
consume sodium-containing sports drinks during their race or game. The early signs of hyponatremia include nausea, muscle
cramps, disorientation, and slurred speech. To learn more about the sports drinks that can optimize your performance, refer back to
Chapter 3, Water and Electrolytes.

Figure : The Effect of Exercise on Sodium Levels.

Image by Allison Calabrese / CC BY 4.0

13.6.2 [Link]
Learning Activities

This page titled 13.6: Water and Electrolyte Needs is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by
Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
16.6: Water and Electrolyte Needs by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0.
Original source: [Link]

13.6.3 [Link]
13.7: Food Supplements and Food Replacements
Current trends also include the use of supplementation to promote health and wellness. Vitamins, minerals, herbal remedies, and
supplements of all kinds constitute big business and many of their advertising claims suggest that optimal health and eternal youth
are just a pill away. Dietary supplements can be macronutrient (amino acids, proteins, essential fatty acids), micronutrient (vitamins
and minerals that promote healthy body functions), probiotic (beneficial bacteria such as the kind found in the intestines), and
herbally ( often target a specific body part, such as bones) based.
Some public health officials recommend a daily multivitamin due to the poor diet of most North Americans. The US Preventive
Task Force also recommends a level of folate intake which can be easier to achieve with a supplement. In addition, the following
people may benefit from taking daily vitamin and mineral supplements:[1]
Women who are pregnant or breastfeeding
Premenopausal women who may need extra calcium and iron
Older adults
People with health issues that affect their ability to eat
Vegetarians, vegans, and others avoiding certain food groups
However, before you begin using dietary supplementation, consider that the word supplement denotes something being added.
Vitamins, minerals, and other assorted remedies should be considered as extras. They are add-ons—not replacements—for a
healthy diet. As food naturally contains nutrients in its proper package, remember that food should always be your primary source
of nutrients. When considering taking supplements, it is important to recognize possible drawbacks that are specific to each kind:[2]
Micronutrient Supplements. Some vitamins and minerals are toxic at high doses. Therefore, it is vital to adhere to the Tolerable
Upper Intake Levels (UL) so as not to consume too much of any vitamin. For example, too much vitamin A is toxic to the liver.
Symptoms of vitamin A toxicity can include tinnitus (ringing in the ears), blurred vision, hair loss, and skin rash. Too much
niacin can cause a peptic ulcer, hyperglycemia, dizziness, and gout.
Herbal Supplements. Some herbs cause side effects, such as heart palpitations and high blood pressure, and must be taken very
carefully. Also, some herbs have contraindications with certain medicines. For example, Valerian and St. John’s Wort negatively
interact with certain prescription medications, most notably antidepressants. Additionally, there is a real risk of overdosing on
herbs because they do not come with warning labels or package inserts.
Amino Acid Supplements. Certain amino acid supplements, which are often taken by bodybuilders among others, can increase
the risk of consuming too much protein. An occasional amino acid drink in the place of a meal is not a problem. However,
problems may arise if you add the supplement to your existing diet. Most Americans receive two to three times the amount of
protein required on a daily basis from their existing diets—taking amino acid supplements just adds to the excess. Also, certain
amino acids share the same transport systems in the absorption process; therefore, a concentrated excess of one amino acid
obtained from a supplement may increase the probability of decreased absorption of another amino acid that uses the same
transport system. This could lead to deficiency in the competing amino acid.

Supplement Claims and Restrictions

The Food and Drug Administration (FDA) regulates supplements, but it treats them like food rather than pharmaceuticals. Dietary
supplements must meet the FDA’s Good Manufacturing Standards, but are not required to meet the standards for drugs, although
some companies do so voluntarily. Also, although supplement manufacturers are allowed to say a particular ingredient may reduce
the risk of a disease or disorder, or that it might specifically target certain body systems, these claims are not approved by the FDA.
This is why labels that make structural and functional claims are required to carry a disclaimer saying the product is not intended
“to diagnose, treat, cure, or prevent any disease.” In addition, in the United States, supplements are taken off the market only after
the FDA has proven that they are hazardous.[3] To revisit the topic of structural and functional claims refer back to Chapter 12
“Nutrition Applications”.

Before Taking Supplements

The phrase caveat emptor means “buyer beware,” and it is important to keep the term in mind when considering supplementation.
Just because a product is “natural” does not mean it can’t be harmful or dangerous, particularly if used inappropriately. The

13.7.1 [Link]
following are helpful questions to explore before deciding to take a supplement:
Does the scientific community understand how this supplement works and are all its effects well known?
Is there proof that the supplement actually performs in the manner that it claims?
Does this supplement interact with food or medication?
Is taking this supplement necessary for my health?
Is the supplement affordable?
Is the supplement safe and free from contaminants?
Lastly, please remember that a supplement is only as good as the diet that accompanies it. We cannot overstate the importance of
eating a healthy, well-balanced diet designed to provide all of the necessary nutrients. Food contains many more beneficial
substances, such as phytochemicals and fiber, that promote good health and cannot be duplicated with a pill or a regimen of
supplements. Therefore, vitamins and other dietary supplements should never be a substitute for food. Nutrients should always be
derived from food first.

Food: The Best Medicine

Poor dietary choices and a sedentary lifestyle account for about 300–600 thousand deaths every year according to the US
Department of Health and Human Services. That number is thirteen times higher than the deaths due to gun violence.[4] The typical
North American diet is too high in saturated fat, sodium, and sugar, and too low in fiber in the form of whole fruits, vegetables, and
whole grains to keep people healthy. With so many threats to optimal health it is vital to address those factors that are under your
control, namely dietary and lifestyle choices. A diet that supplies your body with the needed energy and nutrients daily will result in
efficient body functioning and in protection from disease. Making sound nutritional choices can also provide support for
individuals undergoing treatment for short-term or chronic conditions. Finding a balance between nutritional needs with concerns
about drug interactions can hasten recovery, improve quality of life, and minimize the side effects from treatment protocols.

Learning Activities
1. Nutrition and Athletic Performance. (2016). American College of Sports Medicine. Medicine & Science in Sports & Exercise,
48(3), 543- 568. [Link]/acsm-msse/F...[Link]. Accessed March 17, 2018. ↵
2. Choosing a Vitamin and Mineral Supplement—Topic Overview. [Link]. [Link]/food-recipes/tc/choosing-a-
vitamin -and-mineral-supplement-topic-overview. Last revised March 11, 2018. ↵
3. Watson S. How to Evaluate Vitamins and Supplements. [Link]. [Link]/vitamins-and-supplements/lifestyle-
guide -11/how-to-evaluate-vitamins-supplements. Accessed March 11, 2018. ↵
4. Why Good Nutrition Is Important. [Link]. [Link] Accessed March
9, 2018. ↵

This page titled 13.7: Food Supplements and Food Replacements is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or
curated by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
16.7: Food Supplements and Food Replacements by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC
BY-NC-SA 4.0. Original source: [Link]

13.7.2 [Link]
 CHAPTER OVERVIEW

14: Lifespan Nutrition From Pregnancy to the Toddler Years

Learning Objectives
By the end of this chapter you will be able to:
Describe the physiological basis for nutrient requirements from pregnancy through the toddler years.

14.1: Introduction to Lifespan Nutrition From Pregnancy to the Toddler Years

14.2: Pregnancy
14.3: Infancy
14.4: Toddler Years

This page titled 14: Lifespan Nutrition From Pregnancy to the Toddler Years is shared under a CC BY-NC-SA 4.0 license and was authored,
remixed, and/or curated by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and
standards of the LibreTexts platform.

1
14.1: Introduction to Lifespan Nutrition From Pregnancy to the Toddler Years
I maika‘i ke kalo i ka ‘ohā
The goodness of the taro is judged by the young plant it produces

Figure : Image by Pua O Eleili Pinto / CC BY 4.0

The Human Life Cycle

Human bodies change significantly over time, and food is the fuel for those changes. For example, for Native Hawaiians, expecting
mothers were encouraged to eat greens like the lu‘au (young taro leaves) and palula (young sweet potato leaves) to encourage a
healthy, strong baby. These beliefs and customs practiced in the early stages of life were done in hopes of building a firm
foundation and setting up lifelong health.[1]
People of all ages need the same basic nutrients—essential amino acids, carbohydrates, essential fatty acids, and twenty-eight
vitamins and minerals—to sustain life and health. However, the amounts of nutrients needed differ. Throughout the human life
cycle, the body constantly changes and goes through different periods known as stages. This chapter will focus on pregnancy,
infancy and the toddler years. Chapter 14 will focus on childhood through adolescence and Chapter 15 will focus on the stages of
adulthood. The major stages of the human life cycle are defined as follows:
Pregnancy. The development of a zygote into an embryo and then into a fetus in preparation for childbirth.
Infancy. The earliest part of childhood. It is the period from birth through the first birthday.
Toddler years. Occur during ages one to three and are the end of early childhood.
Childhood. The period from birth to eighteen.
Onset of Puberty. Can occur from ages nine to fourteen, which is the beginning of adolescence.
Older adolescence. The stage that takes place between ages fourteen and eighteen.
Adulthood. The period from the end of adolescence to the end of life and begins at age eighteen in the US and nineteen in some
other countries.
Middle age. The period of adulthood that stretches from age forty-five to sixty-four.
Senior years, or old age. Extend from age sixty-five until the end of life.

14.1.1 [Link]
 Figure : Ultrasound image of a four-month-old fetus.. Image by
Wolfgang Moroder / CC BY-SA 3.0
We begin with pregnancy, a developmental marathon that lasts about forty weeks. It begins with the first trimester (weeks one to
week twelve), extends into the second trimester (weeks thirteen to week twenty-seven), and ends with the third trimester (week
twenty-eight to birth). At conception, a sperm cell fertilizes an egg cell, creating a zygote. The zygote rapidly divides into multiple
cells to become an embryo and implants itself in the uterine wall, where, by the end of the 8th week after conception, it develops
into a fetus. Some of the major changes that occur include the branching of nerve cells to form primitive neural pathways at eight
weeks. At the twenty-week mark, physicians typically perform an ultrasound to acquire information about the fetus and check for
abnormalities. By this time, it is possible to know the sex of the baby. At twenty-eight weeks, the unborn baby begins to add body
fat in preparation for life outside of the womb.[2] The ability to coordinate sucking and swallowing, necessary for feeding at birth,
is not present until 32-34 weeks, and matures around 36-38 weeks gestation.[3]
Throughout this entire process, a pregnant woman’s nutritional choices affect not only fetal development, but also her own health
and the future health of her newborn.

References
1. Pukai MK., Handy ESC. (1958). The Polynesian Family System in Ka-‘u. Rutland, Vermont: Charles E. Tuttle Company ↵
2. Polan EU, Taylor DR. (2003), Journey Across the LifeSpan: Human Development and Health Promotion. Philadelphia: F.A.
Davis Company, 81–82. ↵
3. Stanford Children’s Health. (n.d.). Retrieved June 9, 2020, from [Link]
id=newborn-reflexes-90-P02630↵

This page titled 14.1: Introduction to Lifespan Nutrition From Pregnancy to the Toddler Years is shared under a CC BY-NC-SA 4.0 license and
was authored, remixed, and/or curated by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited
to the style and standards of the LibreTexts platform.
13.1: Introduction to Lifespan Nutrition From Pregnancy to the Toddler Years by Jennifer Draper, Marie Kainoa Fialkowski Revilla, &
Alan Titchenal is licensed CC BY-NC-SA 4.0. Original source: [Link]

14.1.2 [Link]
14.2: Pregnancy
It is crucial to consume healthy foods at every phase of life, beginning in the womb. Good nutrition is vital for any pregnancy and
not only helps an expectant mother remain healthy, but also impacts the development of the fetus and ensures that the baby thrives
in infancy and beyond. During pregnancy, a woman’s needs increase for certain nutrients more than for others. If these nutritional
needs are not met, infants could suffer from low birth weight (a birth weight less than 5.5 pounds, which is 2,500 grams), among
other developmental problems. Therefore, it is crucial to make careful dietary choices.

Figure : Image by Marie Kainoa Fialkowski Revilla / CC BY 4.0

The Early Days of Pregnancy

For medical purposes, pregnancy is measured from the first day of a woman’s last menstrual period until childbirth, and typically
lasts about forty weeks. Major changes begin to occur in the earliest days, often weeks before a woman even knows that she is
pregnant. During this period, adequate nutrition supports cell division, tissue differentiation, and organ development. As each week
passes, new milestones are reached. Therefore, women who are trying to conceive should make proper dietary choices to ensure the
delivery of a healthy baby. Fathers-to-be should also consider their eating habits. A sedentary lifestyle and a diet low in fresh fruits
and vegetables may affect male fertility. Men who drink too much alcohol may also damage the quantity and quality of their sperm.
[1]
.
For both men and women, adopting healthy habits also boosts general well-being and makes it possible to meet the demands of
parenting.

 Tools for Change

A pregnancy may happen unexpectedly. Therefore, it is important for all women of childbearing age to get 400 micrograms of
folate per day prior to pregnancy and 600 micrograms per day during pregnancy. Folate, which is also known as folic acid, is
crucial for the production of DNA and RNA and the formation of cells. A deficiency can cause megaloblastic anemia, or the
development of abnormal red blood cells, in pregnant women. It can also have a profound effect on the unborn baby. Typically,
folate intake has the greatest impact during the first eight weeks of pregnancy, when the neural tube closes. The neural tube
develops into the fetus’s brain and spinal cord, and adequate folate reduces the risk of brain abnormalities and neural tube
defects, which occur in one in a thousand pregnancies in North America each year. This vital nutrient also supports the spinal
cord and its protective coverings. Inadequate folic acid can result in birth defects, such as spina bifida, which is the failure of
the spinal column to close. The name “folate” is derived from the Latin word folium for leaf, and leafy green vegetables such
as spinach and kale are excellent sources of it. Folate is also found in legumes, liver, and oranges. Additionally, since 1998,
food manufacturers have been required to add folate to cereals and other grain products.[2]

14.2.1 [Link]
 Figure : Image by Centers for Disease Control
and Prevention (CDC) / Public Domain

Weight Gain during Pregnancy

During pregnancy, a mother’s body changes in many ways. One of the most notable and significant changes is weight gain. If a
pregnant woman does not gain enough weight, her unborn baby will be at risk. Poor weight gain, especially in the second and third
trimesters, could result not only in low birth weight, but also infant mortality and intellectual disabilities. Therefore, it is vital for a
pregnant woman to maintain a healthy amount of weight gain. Her weight prior to pregnancy also has a major effect. Infant birth
weight is one of the best indicators of a baby’s future health. Pregnant women of normal prepregnancy weight should gain between
25 and 35 pounds in total through the entire pregnancy. The precise amount that a mother should gain usually depends on her
beginning weight or body mass index (BMI). See Table for The Institute of Medicine (IOM) recommendations.
Table : Body Mass Index and Pregnancy[3]

Prepregnancy BMI Weight Category Recommended Weight Gain

Below 18.5 Underweight 28–40 lbs.

18.5–24.9 Normal 25–35 lbs.

25.0–29.9 Overweight 15–25 lbs.

Above 30.0 Obese (all classes) 11–20 lbs.

Starting weight below or above the normal range can lead to different complications. Pregnant women with a prepregnancy BMI
below twenty are at a higher risk of a preterm delivery and an underweight infant. Pregnant women with a prepregnancy BMI
above thirty have an increased risk for a cesarean section during delivery. Therefore, it is optimal to have a BMI in the normal
range prior to pregnancy.
Generally, women gain 2 to 5 pounds in the first trimester. After that, it is best not to gain more than one pound per week. Some of
the new weight is due to the growth of the fetus, while some is due to changes in the mother’s body that support the pregnancy.
Weight gain often breaks down in the following manner as shown in Figure 13.2 6 to 8 pounds of fetus, 1 to 2 pounds for the
placenta (which supplies nutrients to the fetus and removes waste products), 2 to 3 pounds for the amniotic sac (which contains
fluids that surround and cushion the fetus), 1 to 2 pounds in the breasts, 1 to 2 pounds in the uterus, 3 to 4 pounds of maternal
blood, 3 to 4 pounds maternal fluids, and 8 to 10 pounds of extra maternal fat stores that will be needed for breastfeeding and
delivery. Women who are pregnant with more than one fetus are advised to gain even more weight to ensure the health of their
unborn babies.

14.2.2 [Link]
 Figure : Areas of weight
gain for pregnant women
The weight an expectant mother gains during pregnancy is two-thirds to three quarters lean tissue, including the placenta and fetus.
Weight gain is not the only major change. A pregnant woman also will find that her breasts enlarge and that she has a tendency to
retain water[4].
The pace of weight gain is also important. If a woman puts on weight too slowly, her physician may recommend nutritional
counseling. If she gains weight too quickly, especially in the third trimester, it may be the result of edema, or swelling due to excess
fluid accumulation. Rapid weight gain may also result from increased calorie consumption or a lack of exercise.

Weight Loss after Pregnancy

During labor, new mothers lose some of the weight they gained during pregnancy with the delivery of their child. In the following
weeks, they continue to shed weight as they lose accumulated fluids and their blood volume returns to normal. Some studies have
hypothesized that breastfeeding also helps a new mother lose some of the extra weight, although research is ongoing.[5].
New mothers who gain a healthy amount of weight and participate in regular physical activity during their pregnancies also have an
easier time shedding weight post-pregnancy. However, women who gain more weight than needed for a pregnancy typically retain
that excess weight as body fat. If those few pounds increase a new mother’s BMI by a unit or more, that could lead to
complications such as hypertension or Type 2 diabetes in future pregnancies or later in life.

14.2.3 [Link]
Nutritional Requirements
As a mother’s body changes, so do her nutritional needs. Pregnant women must consume more calories and nutrients in the second
and third trimesters than other adult women. However, the average recommended daily caloric intake can vary depending on
activity level and the mother’s normal weight. Also, pregnant women should choose a high-quality, diverse diet, consume fresh
foods, and prepare nutrient-rich meals. Steaming is one of the best ways to cook vegetables. Vitamins are destroyed by
overcooking, whereas uncooked vegetables and fruits have the highest vitamin content. It is also recommended for pregnant
women to take prenatal supplements to ensure adequate intake of the needed micronutrients.

Energy and Macronutrients

During the first trimester, a pregnant woman has the same energy requirements as normal and should consume the same number of
calories as usual. However, as the pregnancy progresses, a woman must increase her caloric intake. According to the IOM, she
should consume an additional 340 calories per day during the second trimester, and an additional 450 calories per day during the
third trimester. This is partly due to an increase in metabolism, which occurs during pregnancy and contributes to increased energy
needs. A woman can easily meet these increased needs by consuming more nutrient-dense foods.
The recommended daily allowance, or RDA, of carbohydrates during pregnancy is about 175 to 265 grams per day to fuel fetal
brain development. The best food sources for pregnant women include whole-grain breads and cereals, brown rice, root vegetables,
legumes, and fruits. These and other unrefined carbohydrates provide nutrients, phytochemicals, antioxidants, and the extra 3
mg/day of fiber that is recommended during pregnancy. These foods also help to build the placenta and supply energy for the
growth of the unborn baby.
During pregnancy, extra protein is needed for the synthesis of new maternal and fetal tissues. Protein builds muscle and other
tissues, enzymes, antibodies, and hormones in both the mother and the unborn baby. Additional protein also supports increased
blood volume and the production of amniotic fluid. The RDA of protein during pregnancy is 71 grams per day, which is 25 grams
above the normal recommendation. Protein should be derived from healthy sources, such as lean red meat, poultry, legumes, nuts,
seeds, eggs, and fish. Low-fat milk and other dairy products also provide protein, along with calcium and other nutrients.
There are no specific recommendations for fats in pregnancy, apart from following normal dietary guidelines. Although this is the
case, it is recommended to increase the amount of essential fatty acids linoleic acid and ∝-linolenic acid because they are
incorporated into the placenta and fetal tissues. Fats should make up 25 to 35 percent of daily calories, and those calories should
come from healthy fats, such as avocados and salmon. It is not recommended for pregnant women to be on a very low-fat diet,
since it would be hard to meet the needs of essential fatty acids and fat-soluble vitamins. Fatty acids are important during
pregnancy because they support the baby’s brain and eye development.

Fluids
Fluid intake must also be monitored. According to the IOM, pregnant women should drink 2.3 liters (about 10 cups) of liquids per
day to provide enough fluid for blood production. It is also important to drink liquids during and after physical activity or when it is
hot and humid outside, to replace fluids lost to perspiration. The combination of a high-fiber diet and lots of liquids also helps to
prevent constipation, a common complaint during pregnancy.
Pregnancy: Body Changes and Discomforts. US Department of Health and Human Services, Office on Women’s Health.
[Link]/pregnanc...t/body-changes -[Link]. Updated September 27, 2010. Accessed December 2, 2017.

Vitamins and Minerals

The daily requirements for nonpregnant women change with the onset of a pregnancy. Taking a daily prenatal supplement or
multivitamin helps to meet many nutritional needs. However, most of these requirements should be fulfilled with a healthy diet.
The following table compares the normal levels of required vitamins and minerals to the levels needed during pregnancy. For
pregnant women, the RDA of nearly all vitamins and minerals increases.
Table : Recommended Nutrient Intakes during Pregnancy

14.2.4 [Link]
 Nutrient Nonpregnant Women Pregnant Women

Vitamin A (mcg) 700.0 770.0

Vitamin B6 (mg) 1.5 1.9

Vitamin B12 (mcg) 2.4 2.6

Vitamin C (mg) 75 85

Vitamin D (mcg) 15 15

Vitamin E (mg) 15 15

Calcium (mg) 1,000.0 1,000.0

Folate (mcg) 400 600

Iron (mg) 18 27

Magnesium (mg) 320 360

Niacin(B3) (mg) 14 18

Phosphorus 700 700

Riboflavin (B2) (mg) 1.1 1.4

Thiamine (B1) (mg) 1.1 1.4

Zinc (mg) 8 11

Source: Nutrition during Pregnancy: Part I: Weight Gain, Part II: Nutrient Supplements. Institute of Medicine.
[Link]/Reports/1990/Nutritio...[Link]. Published January 1, 1990. Accessed November 22, 2017.
Vitamins: [Link] Published by the National
Academies Press; 2011. Accessed April 25, 2020.
Minerals: [Link] Published March 5, 2019.
Accessed April 25, 2020.
The micronutrients involved with building the skeleton—vitamin D, calcium, phosphorus, and magnesium—are crucial during
pregnancy to support fetal bone development. Although the levels are the same as those for nonpregnant women, many women do
not typically consume adequate amounts and should make an extra effort to meet those needs. Many of these nutrient requirements
are higher yet for pregnant mothers who are in their teen years due to higher needs for their own growth in addition to the growth
of the fetus.
There is an increased need for all B vitamins during pregnancy. Adequate vitamin B6 supports the metabolism of amino acids,
while more vitamin B12 is needed for the synthesis of red blood cells and DNA. Also remember that folate needs increase during
pregnancy to 600 micrograms per day to prevent neural tube defects. This micronutrient is crucial for fetal development because it
also helps produce the extra blood a woman’s body requires during pregnancy.
Additional zinc is crucial for cell development and protein synthesis. The need for vitamin A also increases, and extra iron intake is
important because of the increase in blood supply during pregnancy and to support the fetus and placenta. Iron is the one
micronutrient that is almost impossible to obtain in adequate amounts from food sources only. Therefore, even if a pregnant woman
consumes a healthy diet, there still is a need to take an iron supplement, in the form of ferrous salts.
For most other minerals, recommended intakes are similar to those for nonpregnant women, although it is crucial for pregnant
women to make sure to meet the RDAs to reduce the risk of birth defects. In addition, pregnant mothers should avoid exceeding the
Upper Limit recommendations. Taking megadose supplements can lead to excessive amounts of certain micronutrients, such as
vitamin A and zinc, which may produce toxic effects that can also result in birth defects.

14.2.5 [Link]
Guide to Eating during Pregnancy
While pregnant women have an increased need for energy, vitamins, and minerals, energy increases are proportionally less than
other macronutrient and micronutrient increases. So, nutrient-dense foods, which are higher in proportion of macronutrients and
micronutrients relative to calories, are essential to a healthy diet. Examples of nutrient-dense foods include fruits, vegetables, whole
grains, peas, beans, eggs, reduced-fat dairy, and lean meats. Pregnant women should be able to meet almost all of their increased
needs via a healthy diet. However, expectant mothers should take a prenatal supplement to ensure an adequate intake of iron and
folate. Here are some additional dietary guidelines for pregnant women.[6]:
Eat iron-rich or iron-fortified foods, including meat or meat alternatives, breads, and cereals, to help satisfy increased need for
iron and prevent iron-deficiency anemia.
Include vitamin C-rich foods, such as orange juice, broccoli, or strawberries, to enhance iron absorption.
Eat a well-balanced diet, including fruits, vegetables, whole grains, calcium-rich foods, lean meats, and a variety of cooked
seafood (excluding fish that are high in mercury, such as swordfish and shark).
Drink additional fluids, water especially.

Foods to Avoid
A number of substances can harm a growing fetus. Therefore, it is vital for women to avoid them throughout a pregnancy. Some are
so detrimental that a woman should avoid them even if she suspects that she might be pregnant. For example, consumption of
alcoholic beverages results in a range of abnormalities that fall under the umbrella of fetal alcohol spectrum disorders. They include
learning and attention deficits, heart defects, and abnormal facial features (See Figure 13.3). Alcohol enters the unborn baby via the
umbilical cord and can slow fetal growth, damage the brain, or even result in miscarriage. The effects of alcohol are most severe in
the first trimester, when the organs are developing. There is no safe amount of alcohol that a pregnant woman can consume.
Although pregnant women in the past may have participated in behavior that was not known to be risky at the time, such as
drinking alcohol or smoking cigarettes, today we know that it is best to avoid those substances completely to protect the health of
the unborn baby.

Figure : Craniofacial features associated

with fetal alcohol syndrome. Figure by NIH/National Institute on Alcohol Abuse and Alcoholism / Public Domain
Pregnant women should also limit caffeine intake, which is found not only in coffee, but also tea, colas, cocoa, chocolate, and some
over-the-counter painkillers. Some studies suggest that very high amounts of caffeine have been linked to babies born with low
birth weights. The American Journal of Obstetrics and Gynecology released a report, which found that women who consume 200
milligrams or more of caffeine a day (which is the amount in 10 ounces of coffee or 25 ounces of tea) increase the risk of
miscarriage[7].
Consuming large quantities of caffeine affects the pregnant mother as well, leading to irritability, anxiety, and insomnia. Most
experts agree that small amounts of caffeine each day are safe (about one 8-ounce cup of coffee a day or less)[8]. However, that
amount should not be exceeded.

14.2.6 [Link]
Foodborne Illness
For both mother and child, foodborne illness can cause major health problems. For example, the foodborne illness caused by the
bacteria Listeria monocytogenes can cause spontaneous abortion and fetal or newborn meningitis. According to the CDC, pregnant
women are twenty times more likely to become infected with this disease, which is known as listeriosis, than nonpregnant, healthy
adults. Symptoms include headaches, muscle aches, nausea, vomiting, and fever. If the infection spreads to the nervous system, it
can result in a stiff neck, convulsions, or a feeling of disorientation[9].
Foods more likely to contain the bacteria that should be avoided are unpasteurized dairy products, especially soft cheeses, and also
smoked seafood, hot dogs, paté, cold cuts, and uncooked meats. To avoid consuming contaminated foods, women who are pregnant
or breastfeeding should take the following measures:
Thoroughly rinse fruits and vegetables before eating them
Keep cooked and ready-to-eat food separate from raw meat, poultry, and seafood
Store food at 40° F (4° C) or below in the refrigerator and at 0° F (−18° C) in the freezer
Refrigerate perishables, prepared food, or leftovers within two hours of preparation or eating
Clean the refrigerator regularly and wipe up any spills right away
Check the expiration dates of stored food once per week
Cook hot dogs, cold cuts (e.g., deli meats/luncheon meat), and smoked seafood to 160° F before consuming
It is always important to avoid consuming contaminated food to prevent food poisoning. This is especially true during pregnancy.
Heavy metal contaminants, particularly mercury, lead, and cadmium, pose risks to pregnant mothers. As a result, vegetables should
be washed thoroughly or have their skins removed to avoid consuming heavy metals. Maintaining good iron status helps women
not to absorb these heavy metals, so it provides an additional level of protection.
Pregnant women can eat fish, ideally 8 to 12 ounces of different types each week. Expectant mothers are able to eat cooked
shellfish such as shrimp, farm-raised fish such as salmon, and a maximum of 6 ounces of albacore (white) tuna. Canned light tuna
is preferred over canned white albacore tuna because it has lower mercury levels. It is very important for pregnant women to avoid
fish with very high methylmercury levels, such as shark, swordfish, tilefish, and king mackerel. Pregnant women should also avoid
consuming raw fish and shellfish to avoid foodborne illness. The Environmental Defense Fund eco-rates fish to provide guidelines
to consumers about the safest and most environmentally friendly choices. You can find ratings for fish and seafood at
[Link] A Local Guide to Eating Fish Safely from the Hawai‘i Department of Health provides excellent guidance about
eating local fish for pregnant women, nursing mothers, and young children. See: [Link]
Local-Guide-to-Eating-Fish-Safely_2019-[Link]. Updated April 2019. Accessed April 25, 2020.

Physical Activity during Pregnancy

For most pregnant women, physical activity is a must and is recommended in the 2015-2020 Dietary Guidelines for Americans and
the 2018 Physical Activity Guidelines for Americans [10]. Regular exercise of moderate intensity, about thirty minutes per day most
days of the week, keeps the heart and lungs healthy. It also helps to improve sleep and boosts mood and energy levels. In addition,
women who exercise during pregnancy report fewer discomforts and may have an easier time losing excess weight after childbirth.
Brisk walking, swimming, or an aerobics class geared toward expectant mothers are all great ways to get exercise during a
pregnancy. Healthy women who already participate in vigorous activities before pregnancy, such as running, can continue doing so
during pregnancy provided they discuss an exercise plan with their physicians.
However, pregnant women should avoid pastimes that could cause injury, such as soccer, football, and other contact sports, or
activities that could lead to falls, such as horseback riding and downhill skiing. It may be best for pregnant women not to
participate in certain sports, such as tennis, that require you to jump or change direction quickly. Scuba diving should also be
avoided because it might result in the fetus developing decompression sickness. This potentially fatal condition results from a rapid
decrease in pressure when a diver ascends too quickly[11].

Food Cravings and Aversions

Food aversions and cravings do not have a major impact unless food choices are extremely limited. The most common food
aversions are milk, meats, pork, and liver. For most women, it is not harmful to indulge in the occasional craving, such as the desire

14.2.7 [Link]
for pickles and ice cream. However, a medical disorder known as pica occurs during pregnancy more often than in nonpregnant
women. Pica is willingly consuming foods with little or no nutritive value, such as dirt, clay, laundry starch, and large quantities of
ice or freezer frost. In some places this is a culturally accepted practice. However, it can be harmful if these substances take the
place of nutritious foods or contain toxins. Pica is associated with iron deficiency, sometimes even in the absence of anemia, and
iron tends to cure the pica behavior.

Complications during Pregnancy

Expectant mothers may face different complications during the course of their pregnancy. They include certain medical conditions
that could greatly impact a pregnancy if left untreated, such as gestational hypertension and gestational diabetes, which have diet
and nutrition implications.
Gestational hypertension is a condition of high blood pressure during the second half of pregnancy.
First-time mothers are at a greater risk, along with women who have mothers or sisters who had gestational hypertension, women
carrying multiple fetuses, women with a prior history of high blood pressure or kidney disease, and women who are overweight or
who have obesity when they become pregnant. Hypertension can prevent the placenta from getting enough blood, which would
result in the baby getting less oxygen and nutrients. This can result in low birth weight, although most women with gestational
hypertension can still deliver a healthy baby if the condition is detected and treated early.
Some risk factors can be controlled, such as diet, while others cannot, such as family history. If left untreated, gestational
hypertension can lead to a serious complication called preeclampsia and eclampsia, which is sometimes referred to as toxemia of
pregnancy. This disorder is marked by elevated blood pressure and protein in the urine and is associated with swelling. To prevent
preeclampsia, the WHO recommends increasing calcium intake for women consuming diets low in that micronutrient,
administering a low dosage of aspirin (75 milligrams), and increasing prenatal checkups. The WHO does not recommend the
restriction of dietary salt intake during pregnancy with the aim of preventing the development of pre-eclampsia and its
complications[12].
About 4 percent of pregnant women suffer from a condition known as gestational diabetes, which is abnormal glucose tolerance
during pregnancy. The body becomes resistant to the hormone insulin, which enables cells to transport glucose from the blood.
Gestational diabetes is usually diagnosed around twenty-four to twenty-six weeks, although it is possible for the condition to
develop later into a pregnancy. Signs and symptoms of this disease include extreme hunger, thirst, or fatigue. If blood sugar levels
are not properly monitored and treated, the baby might gain too much weight and require a cesarean delivery. Diet and regular
physical activity can help to manage this condition. Most patients who suffer from gestational diabetes also require daily insulin
injections to boost the absorption of glucose from the bloodstream and promote the storage of glucose in the form of glycogen in
liver and muscle cells. Gestational diabetes usually resolves after childbirth, although women who experience this condition are
more likely to develop Type 2 diabetes later in life, particularly if they are overweight.[13].

Reference
1. Healthy Sperm: Improving Your Fertility. Mayo Clinic. 1998–2012 Mayo Foundation for Medical Education and Research.
[Link]/health/fertility/MC00023. Accessed February 21, 2012. ↵
2. Folic Acid. MedlinePlus, a service of the National Institutes of Health. 1995–2012
[Link] Updated August 7, 2011. Accessed November 22, 2017. ↵
3. Weight Gain during Pregnancy: Reexamining the Guidelines. Institute of Medicine.
[Link]
4. Weight Gain during Pregnancy. Utah Department of Health, Baby Your Baby. [Link]
Published 2012. Accessed November 22, 2017. ↵
5. Stuebe AM, Rich-Edwards JW. (2009). The Reset Hypothesis: Lactation and Maternal Metabolism. , American Journal of
Perinatology, 26(1), 81–88. ↵
6. Staying Healthy and Safe. US Department of Health and Human Services, Office on Women’s Health. Last updated March 5,
2009. [Link] Updated February 1,
2017. Accessed November 30, 2017. ↵

14.2.8 [Link]
 7. Weng X, Odouli R, Li DK. (2008). Maternal caffeine consumption during pregnancy and the risk of miscarriage: a prospective
cohort study. American Journal of Obstetrics & Gynecology, 198, 279.e1-279.e8. ↵
8. American Medical Association. (2008). Complete Guide to Prevention and Wellness. Hoboken, NJ: John Wiley & Sons, Inc.,
495. ↵
9. Listeria and Pregnancy. American Pregnancy Association.
[Link] Updated March 10, 2017. Accessed November 29,
2017. ↵
10. -U.S. Department of Health and Human Services. (2018) Physical Activity Guidelines for Americans, 2nd edition. U.S.
Department of Health and Human Services ↵
11. Reid, R. L., & Lorenzo, M. (2018). SCUBA Diving in Pregnancy. Journal of Obstetrics and Gynaecology Canada, 40(11),
1490–1496. [Link] ↵
12. WHO Recommendations for Prevention and Treatment of Pre-eclampsia and [Link] Health Organization.
[Link] Published 2011. Accessed June 9, 2020. ↵
13. Noctor, E., & Dunne, F. P. (2015). Type 2 diabetes after gestational diabetes: The influence of changing diagnostic criteria.
World Journal of Diabetes, 6(2), 234–244. [Link] ↵

This page titled 14.2: Pregnancy is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper,
Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.
13.2: Pregnancy by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original source:
[Link]

14.2.9 [Link]
14.3: Infancy
Diet and nutrition have a major impact on a child’s development from infancy into the adolescent years. A healthy diet not only
affects growth, but also immunity, intellectual capabilities, and emotional well-being. One of the most important jobs of parenting
is making sure that children receive an adequate amount of needed nutrients to provide a strong foundation for the rest of their
lives.

Figure : Image by Marie Kainoa Fialkowski Revilla / CC BY 4.0

Most expectant mothers begin thinking about how they will feed their baby early in their pregnancy. Therefore, it is important to
offer breastfeeding education and support starting with the first prenatal appointment. Support from family members, especially the
baby’s father and grandmother, plus friends, employers, and others can greatly help with both the decision-making process during
pregnancy and the beginning and maintenance of breastfeeding after the baby’s birth. In the United States, about 83.2 percent of
babies start out being breastfed.[1] Yet by the age of six months, when solid foods should begin to be introduced into a child’s diet
along with breast milk, only about 25 percent of infants in the United States were still breastfed exclusively, according to the
Centers for Disease Control and Prevention (CDC).[2]
The approval and assistance of family members, friends, employers, health-care providers, and policymakers can make an
enormous difference and provide the needed promotion and support for mothers who wish to breastfeed their children. Education
about breastfeeding typically begins with health-care providers. During prenatal care and often soon after a woman has given birth,
doctors, nurses, and other clinicians can explain the benefits of breastfeeding and describe the proper technique. Nearly all births in
the United States and Canada occur in hospital settings, and hospital practices in labor, delivery, postpartum care, and discharge
planning can inform and support women who want to breastfeed. Once a new mother has left the hospital for home, she needs
access to a trained individual who can provide consistent information. International Board Certified Lactation Consultants
(IBCLCs) are health-care professionals (often a registered nurse or registered dietitian) certified in breastfeeding management that
work with new mothers to solve problems and educate families about the benefits of this practice. Research shows that
breastfeeding rates are higher among women who had infants in hospitals that make IBCLCs available to new mothers, rather than
those who gave birth in institutions without these professionals on staff.[3]
Other important practices for maternity hospitals to support breastfeeding are summarized in the Ten Steps to Successful
Breastfeeding, launched jointly by the WHO and UNICEF.[4] These recommended practices include: helping mothers initiate
breastfeeding within one hour of birth; keeping mothers and babies together (rooming in); encouraging breastfeeding on demand,
and giving breastfed infants no food or drink other than breastmilk, unless medically indicated.
In addition, spouses, partners, and other family members can play critical roles in helping a pregnant woman make the decision to
breastfeed and assisting with feeding after the baby is born. Employment can also factor into a woman’s decision to breastfeed or

14.3.1 [Link]
her ability to maintain the practice. Employed mothers have been less likely to initiate breastfeeding and tend to breastfeed for a
shorter period of time than new mothers who are not employed or who have lengthy maternity leaves. In 2010 in the United States,
the passage of the Affordable Care Act (ACA) required most employers to provide accommodations within the workplace for new
mothers to pump breast milk. This law requires a private and clean space within the workplace, other than a restroom, along with
adequate break time for a woman to express milk.[5]It also requires health insurance to cover certain breastfeeding services and
supplies such as a breast pump.
Additionally, the Hawai‘i State Legislature has passed several bills to support breastfeeding. These bills provide a number of rights
to breastfeeding women in Hawai‘i. These include: the right to breastfeed in public, the right to pump breastmilk at work
(extending beyond the ACA worksite protections), protection from an employer from firing or penalizing a lactating employee
because the employee breastfeeds or expresses milk at the workplace,[6] and the right for breastfeeding mothers to decline jury duty
until the child is 1 year old.[7] See: [Link]

 Everyday Connection

In the Pacific, the state of Hawai‘i and and the territory of Guam are mandated to provide several accommodations within the
workplace for new mothers. All employers are to required to allow breastfeeding mothers adequate break time to pump or
nurse in location other than a bathroom. To learn more about Hawai‘i’s laws visit
[Link] and for Guam’s laws visit
[Link]

Members of a community can also promote and support breastfeeding. New mothers can join peer counseling groups or turn to
other women within their community who have previous experience with breastfeeding. In addition, community-based programs
can provide education and support. The US Department of Agriculture’s Women, Infants, and Children program provides
information on breastfeeding and both professional and peer support for women and their babies from low-income families.
Launched in 2004, the Loving Support program combines peer counseling with breastfeeding promotion efforts to increase
duration rates across the United States. La Leche League is an international program that provides mother-to-mother support,
encouragement, and education about breastfeeding for women around the world. For more information on La Leche League, visit
[Link] The state coalition, Breastfeeding Hawai‘i, provides a list of local and national resources:
[Link]
Although breastfeeding should be recommended and encouraged for almost all new mothers, it is important to remember that the
decision to breastfeed is a personal choice and women should not be made to feel guilty if they cannot, or choose not, to breastfeed
their infants. In some rare cases, a woman is unable to breastfeed or it is not in the baby’s best interest, for example if the baby has
galactosemia, an inborn error of metabolism.
Nutritional choices that parents make, such as the decision to breastfeed or bottle-feed, not only affect early childhood
development, but also a child’s health and wellness later in life. Therefore, it is imperative to promote and support the best practices
for the well-being of infants and mothers alike.

Infancy (Birth to Age One)

A number of major physiological changes occur during infancy. The trunk of the body grows faster than the arms and legs, while
the head becomes less prominent in comparison to the limbs. Organs and organ systems grow at a rapid rate. Also during this
period, countless synapse pathways to link brain neurons are reinforced while others are trimmed back in the brain. Two soft spots
on the baby’s skull, known as fontanels, allow the skull to accommodate rapid brain growth. The posterior fontanel closes first, by
the age of eight weeks. The anterior fontanel closes about a year later, at eighteen months on average. Developmental milestones
include sitting up without support, learning to walk, teething, and vocalizing among many, many others. All of these changes
require adequate nutrition to ensure development at the appropriate rate.[8]

14.3.2 [Link]
 Figure : Image by Marie Kainoa Fialkowski Revilla / CC BY 4.0
Healthy infants grow steadily, but not always at an even pace. For example, during the first year of life, height increases by 50
percent, while weight triples. Physicians and other health professionals use growth charts to track a baby’s development process.
Because infants cannot stand, length is used instead of height to determine the rate of a child’s growth. Other important
developmental measurements include head circumference and weight. All of these must be tracked and compared against standard
measurements for an infant’s age.
In the US, for infants and toddlers from birth to 24 months of age, the WHO growth charts are used to monitor growth. These
standards represent optimal growth for children at this age and allow for tracking growth trends over time through percentile
rankings. Growth charts may provide warnings that a child has a medical problem or is malnourished. Growth that is too rapid can
increase the risk for overweight and obesity in childhood and later in life. Insufficient weight or height gain during infancy may
indicate a condition known as failure-to-thrive (FTT), which is characterized by poor growth. FTT can happen at any age, but in
infancy, it typically occurs after six months. Some causes include poverty, lack of enough food, feeding inappropriate foods, and
excessive intake of fruit juice.

14.3.3 [Link]
 Figure :
WHO Growth Chart For Boys From Birth To 24 Months. Image by Centers for Disease Control and Prevention / Public Domain

Nutritional Requirements
Requirements for macronutrients and micronutrients on a per-kilogram basis are higher during infancy than at any other stage in
the human life cycle. These needs are affected by the rapid cell division that occurs during growth, which requires energy and
protein, along with the nutrients that are involved in synthesis of DNA and other cellular components. During this period, children

14.3.4 [Link]
are entirely dependent on their parents or other caregivers to meet these needs. For almost all infants six months or younger, breast
milk is the best source to fulfill nutritional requirements. An exclusively breastfed infant does not even need extra water, including
in hot climates.
A newborn infant (birth to 28 days) requires feedings eight to twelve times a day or more. Between 1 and 3 months of age, the
breastfed infant becomes more efficient, and the number of feedings per day often become fewer even though the amount of milk
consumed stays the same. After about six months, infants can gradually begin to consume solid foods to help meet nutrient needs.
Foods that are added in addition to breastmilk are called complementary foods. Complementary foods should be nutrient dense to
provide optimal nutrition. Complementary foods include baby meats, vegetables, fruits, infant cereal, and dairy products such as
yogurt, but not infant formula. Infant formula is a substitute, not a complement to breastmilk. In addition to complementary foods,
the World Health Organization recommends that breastfeeding continue up to 2 years of age or beyond, and the American Academy
of Pediatrics recommends at least one year of breastfeeding, or longer. [9]

Energy and Macronutrients

Energy needs relative to size are much greater in an infant than an adult. A baby’s resting metabolic rate is two times that of an
adult. The RDA to meet energy needs changes as an infant matures and puts on more weight. The IOM uses a set of equations to
calculate the total energy expenditure and resulting energy needs. For example, the equation for the first three months of life is (89
x weight [kg] −100) + 175 kcal.
Based on these equations, the estimated energy requirement for infants from zero to six months of age is 472 to 645 kilocalories per
day for boys and 438 to 593 kilocalories per day for girls. For infants ages six to twelve months, the estimated requirement is 645
to 844 kilocalories per day for boys and 593 to 768 kilocalories per day for girls. From the age one to age two, the estimated
requirement rises to 844–1,050 kilocalories per day for boys and 768–997 kilocalories per day for girls.[10] How often an infant
wants to eat will also change over time due to growth spurts, which typically occur at about two weeks and six weeks of age, and
again at about three months and six months of age.
The dietary recommendations for infants are based on the nutritional content of human breast milk. Carbohydrates make up about
40 to 55percent of the caloric content in breast milk, which amounts to a RDA (AI) of about 60 grams for infants 0-6 months old,
and 95 grams for infants 7-12 months old. Almost all of the carbohydrate in human milk is lactose, which infants digest and
tolerate well. In fact, lactose intolerance is practically nonexistent in infants. Protein makes up about 5 to 9 percent of the caloric
content of breast milk, which amounts to a RDA (AI) of 9.1 grams per day for infants 0-6 months, and a RDA of 11 grams per day
for infants 7-12 months. Infants have a high need for protein to support growth and development, although excess protein (which is
only a concern with bottle-feeding) can cause dehydration, diarrhea, fever, and acidosis in premature infants. About 30 to 50
percent of the caloric content in breast milk is made up of fat. A high-fat diet that includes cholesterol is necessary to support the
development of neural pathways in the brain and throughout the body. However, saturated fats and trans fatty acids inhibit this
growth. Infants who are over the age of six months, which means they are receiving complementary foods, should not consume
foods that are high in these types of fats. The RDA (AI) for total fat is 30 grams per day for infants 0-6 months old and 31 grams
per day for infants 7-12 months old.

Micronutrients
Almost all of the nutrients that infants require during the first 6 months can be met if they consume an adequate amount of breast
milk. There are a few exceptions, though. Unless the mother is taking a large dose of Vitamin D, human milk will be low in vitamin
D, which is needed for calcium absorption and building bone, among other things. Therefore, breastfed children often need to take
a vitamin D supplement in the form of drops. Infants at the highest risk for vitamin D deficiency are those with darker skin and
little to no exposure to sunlight, and infants born prematurely. Breast milk is also low in vitamin K[11], which is required for blood
clotting, and deficits could lead to bleeding or hemorrhagic disease. Babies are born with limited vitamin K, so supplementation
may be needed initially and some states require a vitamin K injection after birth. Also, breast milk is not high in iron, but the iron in
breast milk is well absorbed by infants. After five to eight months, however, an infant needs an additional source of iron other than
breast milk. For exclusively breastfed infants, 6 months of age is a good time to introduce sources of highly bioavailable iron and
zinc such as baby meats. Iron-fortified cereals and beans can boost the iron intake as well.

14.3.5 [Link]
Fluids
Infants have a high need for fluids, 1.5 milliliters per kilocalorie consumed compared to 1.0 milliliters per kilocalorie consumed for
adults. This is because children have larger body surface area per unit of body weight and a higher metabolic rate. Therefore, they
are at greater risk of dehydration. However, parents or other caregivers can meet an infant’s fluid needs with breast milk or
formula. As solids are introduced, parents must make sure that young children continue to drink fluids throughout the day.

Breastfeeding
Although few aspects of human nutrition are surrounded by as much public controversy as is the choice to breastfeed or formula
feed an infant, a little knowledge about the science of breastfeeding can go a long way to settling this debate. This section will
cover the science of lactation and practical ways to improve both the breastfeeding experience and the nutritional status of mothers
and infants. Learning about the different parts of the breast and their function is a first step to becoming better able to support
mothers who want to breastfeed.

Figure : Copy and Paste Caption here.

(Copyright; author via source)
The structure of the breast includes the alveoli which are grape-like clusters where milk is made. A network of ducts branch out and
carry the milk from the alveoli to the nipple. A tiny muscle surrounds each of the alveoli; when a baby nurses at the breast, a
hormone is released from the mother’s brain that makes these muscles contract and push the milk out into the ducts and towards the
nipple. Groups of alveoli connected by ducts are organized into lobes, or sections, of the breast. The breast contains 15 to 25 lobes,
and each lobe contains 10 to 100 alveoli.
The areola is the darker skin around the nipple and is a visual target that helps the baby find the breast. The bumps on the areola are
glands that provide lubrication and protection to the tissue. These glands also produce a scent to help the baby find the nipple. The
nipple and areola contain erectile smooth muscles that contract to make the nipple protrude more during breastfeeding. Nipples
come in many sizes and shapes and contain from 4 to 18 openings for the milk to flow out. Mothers do not need to do anything to
get their nipples ready to breastfeed.
Breast size is mainly determined by the amount of fat in the breast; the milk-making structures don’t vary as much as the amount of
fat tissue. Most mothers can make enough milk for their babies whether they have small or large breasts. It is normal for a woman
to have one breast that is different than the other in size or shape. During pregnancy, the breasts will normally increase in size. If a
woman does not notice any changes to her breast during pregnancy, she should discuss this with her healthcare provider or a
lactation consultant.

14.3.6 [Link]
After the birth of the baby, nutritional needs must be met to ensure that an infant not only survives, but thrives from infancy into
childhood. Breastfeeding provides the fuel a newborn needs for rapid growth and development. As a result, the WHO recommends
that breastfeeding is exclusive (no other food or drink) for the first six months of an infant’s life. Exclusive breastfeeding is one of
the best ways a mother can support the growth and protect the health of her infant child. Breast milk contains nearly all of the
nutrients that a newborn requires and gives a child the best start to a healthy life. Most women want to breastfeed their babies; in
the US, over 80% of women start to breastfeed their infants. Unfortunately, a mother’s intention alone may not be enough to make
this practice successful. Around the world, approximately 40 percent of infants are breastfed exclusively for the recommended 6
months.[12][13][14]
New mothers must also pay careful consideration to their own nutritional requirements to help their bodies recover in the wake of
the pregnancy. This is particularly true for women who breastfeed their babies, which increases the need in certain nutrients.

Lactation
Preparation for making breast milk, although begun in puberty, is not completed until a woman’s first pregnancy. Early in the first
trimester, the cells that will secrete milk divide and multiply. Hormones play a major role in preparing the woman’s body to
breastfeed, particularly during the second and third trimesters. At that point, levels of the hormone prolactin increase to stimulate
the growth of the milk duct system, which initiates and maintains milk production. Also during pregnancy, progesterone stimulates
growth of the alveoli, the clusters of cells where the milk is made. During this process ducts that will carry the milk grow larger and
branch out, and new capillaries are also formed to circulate the increased blood supply. However, levels of the hormone
progesterone need to decrease for successful milk production, because progesterone inhibits milk secretion. Shortly after birth, the
expulsion of the placenta triggers progesterone levels to fall, which activates lactation.[15] When the infant suckles at the breast,
levels of the hormone oxytocin rise to promote the release of breast milk from the breast when the infant suckles, which is known
as the milk-ejection reflex.
New mothers usually find that their appetite and thirst is greater than before pregnancy; it is recommended that they still focus on
nutrient-dense foods to nourish their body and replace their body’s nutrient stores. A conservative rate of weight loss (1-2 pounds
per week) during lactation does not usually impact the quantity or quality of breast milk, but maternal deficiencies in some
nutrients have been described during lactation. The nutrient content of breastmilk does not change much based upon maternal diet
for most nutrients. The RDA for energy is 330 additional Calories during the first six months of lactation and 400 additional
Calories during the second six months of lactation. The energy needed to support breastfeeding comes from both increased intake
and from stored fat. For example, during the first six months after her baby is born, the daily caloric cost for a lactating mother is
500 Calories, with 330 calories derived from increased intake and 170 Calories derived from maternal fat stores. This helps explain
why breastfeeding may promote weight loss in new mothers. Lactating women should also drink 3.1 liters of liquids per day (about
13 cups) to avoid dehydration, according to the IOM. As is the case during pregnancy, the RDA of most vitamins and minerals
increases for women who are breastfeeding their babies. Most doctors and nutritionists recommend that lactating women continue
taking their prenatal vitamin/mineral supplement during lactation. The following table compares the recommended vitamins and
minerals for lactating women to the levels for nonpregnant and pregnant women.
Table : Recommended Nutrient Intakes during Lactation

14.3.7 [Link]
 Nutrient Nonpregnant Women Pregnant Women Lactating Women

Vitamin A (mcg) 700.0 770.0 1,300.0

Vitamin B6 (mg) 1.3 1.9 2.0

Vitamin B12 (mcg) 2.4 2.6 2.8

Vitamin C (mg) 75.0 85.0 120.0

Vitamin D (mcg) 5.0 5.0 5.0

Vitamin E (mg) 15.0 15.0 19.0

Calcium (mg) 1,000.0 1,000.0 1,000.0

Folate (mcg) 400.0 600.0 500.0

Iron (mg) 18.0 27.0 9.0

Magnesium (mg) 310.0 350.0 310.0

Niacin (B3) (mg) 14.0 18.0 17.0

Phosphorus 700.0 700.0 700.0

Riboflavin (B2) (mg) 1.1 1.4 1.6

14.3.8 [Link]
 Nutrient Nonpregnant Women Pregnant Women Lactating Women

Thiamine (B1) (mg) 1.1 1.4 1.4

Zinc (mg) 8.0 11.0 12.0

Source: Institute of Medicine (2006). Dietary reference intakes: The essential guide to nutrient requirements. The National
Academies Press. [Link]
Calcium requirements do not change during breastfeeding because of more efficient absorption, which is the case during
pregnancy, too. However, the reasons for this differ. During pregnancy, there is enhanced absorption within the gastrointestinal
tract. During lactation, there is enhanced retention by the kidneys. The RDA for phosphorus and fluoride also remains the same.

Components of Breastmilk
Human breast milk not only provides adequate nutrition for infants, it also helps to protect newborns from disease. In addition,
breast milk is rich in cholesterol, which is needed for brain development. It is helpful to know the different types and components
of breastmilk, along with the nutrients they provide to enable an infant to survive and thrive.
Colostrum is the milk produced immediately after birth, prior to the start of mature milk production, and lasts for two to five days
after the arrival of the baby. Cells in the breast can begin to secrete colostrum by mid-pregnancy. During the last trimester, the
alveoli (grape-like clusters of cells that produce milk) can become swollen with colostrum. Colostrum is thicker than mature breast
milk, and is yellowish or creamy in color. This protein-rich liquid fulfills an infant’s nutrient needs during those early days.
Although low in volume, colostrum is packed with concentrated nutrition for newborns. This special milk is high in fat-soluble
vitamins, minerals, and immunoglobulins (antibodies) that pass from the mother to the baby. Immunoglobulins provide passive
immunity for the newborn and protect the baby from bacterial and viral diseases.[16] Colostrum also helps the baby to eliminate
waste (meconium).
Two to four days after birth, colostrum is replaced by transitional milk. Nursing the baby early (within the first hour of birth) and
frequently (8 to 14 times per 24 hours) helps to bring in this increased volume of milk sooner. Transitional milk is a creamy, usually
yellow liquid that lasts for approximately two weeks and includes high levels of fat, lactose, and water-soluble vitamins. It also
contains more calories than colostrum. As a new mother begins to produce transitional milk, she typically notices an increase in the
weight and size of her breasts and a change in the volume and type of liquid secreted.[17]
Mature milk is the final milk that a new mother produces. Its composition varies from morning to night, from the beginning of the
feeding to the end, and from early postpartum to later in infancy and toddlerhood. Breastmilk that is produced by mothers of
premature infants is higher in protein and calcium to meet the needs of the preemie. Foremilk (the milk that comes at the beginning
of a feeding) tends to be lower in fat. Hind-milk comes towards the end of a feeding containing higher levels of fat, which helps the
baby to feel satisfied and full. Combined, these two types of milk ensure that a baby receives adequate nutrients to grow and
develop properly.[18]
About 87.5 percent of mature milk is water, which helps an infant remain hydrated. The other 12.5 percent contains carbohydrates,
proteins, fats, vitamins and minerals which support energy and growth. Similar to cow’s milk, the main carbohydrate of mature
breast milk is lactose. Breast milk contains the essential fatty acids, linoleic acid and alpha-linolenic acid, and other fats that are
important for development such as docosahexaenoic acid (DHA). In terms of protein, breast milk contains more whey than casein
(which is the reverse of cow’s milk). Whey is much easier for infants to digest than casein. Casein and whey make a complete
protein with all of the essential amino acids. Another protein in breastmilk, lactoferrin is an iron-binding protein that helps keep
iron away from pathogenic bacteria and facilitates the absorption of iron into an infant’s bloodstream.

14.3.9 [Link]
For most vitamins and minerals, breast milk provides adequate amounts for growth and maintenance of optimal health. Although
the absolute amounts of some micronutrients are low, they are more efficiently absorbed by infants from breast milk. Other
essential components include digestive enzymes that help a baby digest the breast milk. Human milk also provides the hormones
and growth factors that help a newborn to develop.

Diet and Milk Quality

A mother’s health habits can impact milk production and quality. As during pregnancy, lactating mothers should avoid illegal
substances and cigarettes. Some legal drugs and herbal products can be harmful as well, so it is helpful to discuss them with a
healthcare professional. In some rare cases, mothers may need to avoid certain things, such as dairy or spicy foods, that can
produce gas in sensitive infants. Lactating women can drink alcohol, though they must avoid breastfeeding until the alcohol has
completely cleared from their milk. Typically, this takes two to three hours for 12 ounces of beer, 5 ounces of wine, or 1.5 ounces
of liquor, depending on a woman’s body weight.[19] Precautions are necessary because exposure to alcohol can negatively affect
infant growth.

Benefits of Breastfeeding
Breastfeeding has a number of benefits, both for the mother and for the child. Breast milk contains immunoglobulins, enzymes,
immune factors, and white blood cells. As a result, breastfeeding boosts the baby’s immune system and lowers the incidence of
diarrhea, respiratory diseases, gastrointestinal infections, and ear infections. Breastfed babies also are less likely to develop asthma
and allergies, and breastfeeding lowers the risk of sudden infant death syndrome. In addition, human milk encourages the growth of
a healthy microbiome (the bacteria in an infant’s intestinal tract). Most of these benefits remain after an infant has been weaned
from breast milk. Some studies suggest other possible long-term effects. For example, breast milk may improve an infant’s
intelligence and protect against Type 1 diabetes and obesity, although research is ongoing in these areas.[20]
Breastfeeding has a number of other important benefits. It is easier for babies to digest breast milk than infant formula, which
contains proteins made from cow’s milk or soybeans that are harder to tolerate. Breastfed infants are sick less often than bottle-fed
infants. Breastfeeding is more sustainable and results in less plastic waste and other trash. Breastfeeding can also save families
money because it typically saves over $1,200 per year in the US over purchasing formula. Other benefits include that breast milk is
always ready. It does not have to be mixed, heated, or prepared. Also, breast milk is sterile and is always at the right temperature.
In addition, the skin-to-skin contact of breastfeeding promotes a close bond between mother and baby, which is an important
emotional and psychological benefit. The practice also provides health benefits for the mother. Breastfeeding reduces the risk of
Type 2 Diabetes in the mother and infant. Studies have also shown that breastfeeding reduces the risk of breast and ovarian cancers.
[21]

 The Baby-Friendly Hospital Initiative

In 1991, the WHO and UNICEF launched the Baby-Friendly Hospital Initiative (BFHI), which works to ensure that all
maternity care facilities, including hospitals and free-standing facilities, become centers of breastfeeding support. A maternity
care facility can be denoted as “baby-friendly” when it does not accept free infant formula and has implemented The Ten Steps
to Successful Breastfeeding. These steps include having a written policy on breastfeeding communicated to health-care staff on
a routine basis, informing all new mothers about the benefits and management of breastfeeding, showing new mothers how to
breastfeed their infants, and how to maintain lactation, and giving newborns no food or drink other than breast milk, unless
medically indicated. Since the BFHI began, more than fifteen thousand facilities in 134 countries, from Benin to Bangladesh,
have been deemed “baby friendly.” As a result, more mothers are breastfeeding their newborns and infant health has improved,
in both the developed world and in developing nations.[22] For information on the Baby-Friendly Initiative in the US, see:
[Link]

Barriers to Breastfeeding
Although breast milk is ideal for almost all infants, there are some challenges that nursing mothers may face when starting and
continuing to breastfeed their infants. These obstacles include painful engorgement or fullness in the breasts, often around day 3 to
5 postpartum, sore and tender nipples, lack of comfort or confidence in public, and lack of accommodation to breastfeed or express
milk in the workplace.

14.3.10 [Link]
One of the first challenges nursing mothers face is learning how to comfortably position the baby at her breast. Improper position
and latching usually results in pain for the mother and inadequate intake for the infant, which could slow growth and development.
However, all International Board Certified Lactation Consultants (IBCLCs) and most Obstetric nurses are trained to help new
mothers learn the proper technique. Some registered dietitians are trained in lactation support as well. A very helpful position for
new mothers is called the “Laid-Back Nursing” position, and it usually helps mother and baby to feel more comfortable, and helps
baby to latch on without causing any nipple pain. Resources on the laid back position can be found here: [Link]
and-relax-a-look-at-laid-back-breastfeeding/
Education, the length of maternity leave, and laws to protect public breastfeeding, among other measures, can all help to facilitate
breastfeeding for many lactating women and their newborns. The laws specific to Hawai‘i and the other states can be found at:
[Link]

Contraindications to Breastfeeding
Although there are numerous benefits to breastfeeding, in some cases there are also risks that must be considered. In the developed
world, a new mother with HIV should not breastfeed, because the infection can be transmitted through breast milk. These women
typically have access to infant formula and water that is safe, and can be used as a replacement for breast milk. However, in
developing nations where HIV infection rates are high and acceptable infant formula can be difficult to find, many newborns would
be deprived of the nutrients they need to develop and grow. Also, inappropriate or contaminated infant formulas cause 1.5 million
infant deaths each year. As a result, the WHO recommends that women infected with HIV in the developing world should nurse
their infants while taking antiretroviral medications to lower the risk of transmission.[23] In any case, combination feeding (formula
and breastmilk together) is not recommended for mothers who are HIV positive because the risk of transmitting HIV to the infant is
higher than either breastfeeding or formula feeding alone.
Breastfeeding also is not recommended for women undergoing radiation or chemotherapy treatment for cancer. Additionally, if an
infant is diagnosed with galactosemia, meaning an inability to process the simple sugar galactose, the child must be on a galactose-
free diet, which excludes breast milk. This genetic disorder is a very rare condition, however, and only affects 1 in thirty- to sixty-
thousand newborns.[24] When breastfeeding is contraindicated for any reason, feeding a baby formula enables parents and
caregivers to meet their newborn’s nutritional needs.

Bottle-Feeding
Most women can breastfeed when given sufficient education and support. However, as discussed, a small percentage of women are
unable to breastfeed their infants, while others choose not to. For parents who choose to bottle-feed, infant formula provides a
balance of nutrients. However, not all formulas are the same and there are important considerations that parents and caregivers
must weigh. Standard formulas use cow’s milk as a base. They have 20 calories per fluid ounce, similar to breast milk, with
vitamins and minerals added. Often parents start their babies on soy formula because they incorrectly assume that soy formula will
reduce allergies and other health problems, but this is not the case. Soy-based formulas are sometimes given to infants who develop
diarrhea, constipation, vomiting, colic, or abdominal pain, but more often these babies are put on hydrolysate formula to address
these concerns. Hypoallergenic protein hydrolysate formulas are given to infants who are allergic to cow’s milk and soy protein, or
who have trouble tolerating them. This type of formula uses hydrolyzed protein, meaning that the protein is broken down into
amino acids and small peptides, which makes it easier to digest, and makes it less likely to trigger gastrointestinal distress.
Preterm infant formulas are given to premature and low birth weight infants, if breast milk is unavailable. Preterm infant formulas
have 24 calories per fluid ounce and are given until the infant reaches a desired weight. These formulas are also higher in protein,
calcium, and phosphorus to meet the special needs of premature infants.
Infant formula comes in three basic types:
1. Powder that requires mixing with water. This is the least expensive type of formula.
2. Concentrates, which are liquids that must be diluted with water. This type is slightly more expensive.
3. Ready-to-use liquids that can be poured directly into bottles. This is the most expensive type of formula. However, it requires
no preparation. Ready-to-use formulas are used when a safe and sanitary water supply is not available. Ready-to-use formulas
are also convenient for traveling.

14.3.11 [Link]
Most babies need about 2.5 ounces of formula per pound of body weight each day. Therefore, the average infant consumes about
24 fluid ounces of breastmilk or formula per day, or one ounce per hour. If an infant sleeps for 2 hours, they often consume 2
ounces of breastmilk or formula at their next feeding. When preparing formula, parents and caregivers should carefully follow the
mixing instructions and safety guidelines, since an infant has an immature immune system. All equipment used in formula
preparation should be sterilized for newborns, and especially premature infants. Prepared, unused formula should be refrigerated to
prevent bacterial growth. A partially finished bottle of infant formula should be discarded after 1 hour. Parents must make sure not
to use contaminated water to mix formula in order to prevent foodborne or other illnesses. Follow the instructions for powdered
and concentrated formula carefully—formula that is overly diluted will not provide adequate calories and protein, while overly
concentrated formula provides too much protein and too little water which can challenge immature kidneys and lead to
dehydration.
Around 6 months of age, infants can start sipping expressed breast milk, infant formula, or water from a cup. By 12 to 14 months
of age, children should be using a cup for all liquids.
It is important to note again that both the American Academy of Pediatrics and the WHO state that breast milk is far superior to
infant formula. This table compares the advantages of giving a child breast milk to the disadvantages of using bottle formula.
Table : Breast Milk versus Bottle Formula

Breast Milk Bottle Formula

Antibodies and lactoferrin in breast milk protect infants. Formula does not contain immunoprotective factors.

The iron in breast milk is absorbed more easily. Because the iron
Formula contains more iron than breast milk, but it is not absorbed
is bound to lactoferrin, it is not available for bacteria in the gut to
as easily, and the iron is a growth factor for pathogenic microbes.
use as a growth factor.

The feces that babies produce do not smell because breastfed The feces that bottle-fed infants produce tends to have a foul-
infants have different bacteria in the gut. smelling odor.

Breast milk is always available and is always at the correct Formula must be prepared, refrigerated for storage, and warmed
temperature. before it is given to an infant.

Breastfed infants are less likely to have constipation. Bottle-fed infants are more likely to have constipation.

Breastfeeding ostensibly is free, though purchasing optional

Formula must be purchased and is expensive, typically costing
supplies such as a pump and bottles to express milk does require
over $1,200 in the first year.
some expense.

Breast milk contains the fatty acids DHA and EPA, which are vital
Some formulas contain DHA and EPA.
for brain and vision development.

Source: American Pregnancy Association (2019, October 14). Breastfeeding versus bottle feeding.
[Link]

Introducing Solid Foods

Infants should be breastfed or bottle-fed exclusively for the first six months of life according to the WHO. Foods that are added in
addition to breastmilk are called complementary foods. Complementary foods should be nutrient dense to provide optimal
nutrition. Complementary foods include baby meats, vegetables, fruits, infant cereal, and dairy products such as yogurt, but not
infant formula. Infant formula is a substitute, not a complement to breastmilk.
Infants should not consume solid foods prior to six months because most solids are less nutritious than breastmilk. Eating solids
before 6 months of age usually means drinking less breast milk and is associated with more ear infections and respiratory
infections. If parents try to feed an infant who is too young or is not ready, their tongue will push the food out; this is called an
extrusion reflex. After six months, the suck-swallow reflexes are not as strong, and infants can hold up their heads and move them
around, both of which make eating solid foods more feasible.

14.3.12 [Link]
Solid baby foods can be bought commercially or prepared from regular food using a food processor, blender, food mill, or grinder
at home. By nine months to a year, infants are able to chew soft foods and can eat solids that are well chopped or mashed. Infants
who are fed solid foods before 4 months of age are susceptible to developing food allergies. Therefore, as parents and caregivers
introduce solids, they should feed their child only one new food at a time, to help identify allergic responses or food intolerances.
An iron supplement is also recommended at this time. Rice is no longer recommended for a first infant food because of its high
arsenic content. When cereals are introduced, parents can try baby oats or baby wheat.
A guide to infant feeding can be found in the 2019 USDA Infant Nutrition and Feeding Guide at:
[Link]

 Everyday Connection

Different cultures have specific food customs. In ancient Hawai‘i, poi (pounded taro) was a staple food in the diet and is still
popular today due to it’s nutrient-dense structure.

Figure
Poi is high in easily digestible calories, a good source of potassium along with a number of other essential vitamins and
minerals. Poi also has many gastrointestinal tract health benefits due to its fiber and probiotic content. With it’s viscous texture,
poi is an excellent first food for infants to consume.

Complementary Foods
Guidelines for feeding healthy infants from the USDA Infant Nutrition and Feeding Guidelines are adapted in the table below.
Table : Guidelines for Feeding Healthy Infants Birth to 12 Months Old

14.3.13 [Link]
 Human Milk or
Age Grain products Vegetables Fruit Protein-rich foods
infant formula

Newborns
breastfeed 8-12
times/day. Formula
fed infants should
Birth – 6 months consume 2-3 ounces None None None None
of formula every 3-
4 hours and by 6
months consume 32
ounces/day.

Breastfed infants
continue to
breastfeed, on
demand.
Formula-fed infants About 1-2 ounces
take in about 24-32 meat, poultry, fish,
About 1-2 ounces About 2-4 ounces of About 2-4 ounces of
ounces. Amounts eggs, cheese, yogurt,
iron-fortified infant cooked, plain, plain
6-8 months vary based on or legumes; all are
cereals, bread, small strained/pureed/mas strained/pureed/mas
individual plain
pieces of crackers h vegetables hed fruits
assessment. strained/pureed/
Intake of human mashed
milk or formula
may decrease as
complementary
foods increase.

Guide/encourage
breastfeeding
mothers and
continue to support About 2-4 ounces
About 2-4 ounces
mothers who choose iron-fortified infant
meat, poultry, fish,
to breastfeeding cereals; other About 4-6 ounces, About 4-6 ounces,
eggs, cheese, yogurt,
8-12 months beyond 12 months. grains: baby ground/finely ground/finely
or mashed legumes;
Formula-fed infants crackers, bread, chopped/diced chopped/diced
all are ground/finely
take in about 24 noodles, corn, grits,
chopped/diced
ounces. Amounts soft tortilla pieces
vary based on
individual nutrition
assessment.

Source:
Kleinman, R. E. G., Frank R. (Ed.). (2013). Pediatric nutrition, 7th Edition . American Academy of Pediatrics.
Holt, K., Woodridge, N. H., Story, M., & Sofka, D. (Eds.). (2011). Bright futures nutrition, 3rd Edition . American Academy of
Pediatrics.
American Academy of Pediatrics. (2012). Breastfeeding and the use of human milk. Pediatrics , 129 (3), e827.
American Academy of Pediatrics. (2018. September 24). Amount and schedule of formula feedings.
[Link]
Leonberg, B. L. (2020). Pocket guide to pediatric nutrition assessment, 2nd ed. Academy of Nutrition and Dietetics.

14.3.14 [Link]
NOTE: These are general guidelines for the healthy, full-term infant per day; serving sizes may vary with individual infants. Start
complementary foods when developmentally ready, about 6 months; start with about 0.5-1 ounce.

Foods to Avoid
Many foods can cause harm to infants, including:
Honey should never be given to a child under 12 months, including honey graham crackers and other foods with honey.
Cow’s Milk should never be given to a child under 12 months.
Syrups, Sugars, Artificial Sweeteners, and Sugar-Sweetened Beverages
Vegetables High in Nitrates – spinach, beets, carrots, collard greens, or turnips should not be fed to infants less than 6 months of
age.
Raw or Partially Cooked Meat, Fish, or Poultry
Certain foods should also be avoided as they are choking hazards. These foods are listed in the table from the USDA Infant
Nutrition and Feeding Guidelines.
Table : Common Foods That Cause Choking in Children Under Age 4

Vegetables Fruits Protein-rich foods Grain products Other foods and snacks

Tough or large chunks of

Small pieces of raw meat Hard or round candy
Apples or other hard
vegetable (like raw Hot dogs, meat sticks, or Jelly beans
pieces of raw fruit,
carrot rounds, baby sausages (even when cut Caramels
especially those with
carrots, string beans, or into round slices) Gum drops, gummy
hard pits or seeds Plain wheat germ
celery), or other raw, Fish with bones candies, or other gooey
Large, hard pieces of Whole-grain kernels
partially cooked Large chunks of cheese or sticky candy
uncooked dried fruits Crackers or breads with
vegetables or string cheese Chewy fruit snacks
Whole pieces of canned seeds
Raw green peas Peanuts, nuts, or seeds Chewing gum
fruit Nut pieces
Cooked or uncooked (like sunflower or Marshmallows
Whole grapes, cherries, Hard pretzels
whole corn kernels pumpkin seeds) Popcorn, potato or corn
berries, melon balls, or
Large, hard pieces of Chunks or spoonfuls of chips, or similar snack
cherry and grape
uncooked dried peanut butter or other foods
tomatoes
vegetables nut and seed butters Ice cubes
Whole beans

Learning to Self-Feed
With the introduction of solid foods, young children begin to learn how to handle food and how to feed themselves. At six to seven
months, infants can use their whole hand to pick up items (this is known as the palmer grasp). They can lift larger items, but
picking up smaller pieces of food is difficult. At eight months, a child might be able to use a pincer grasp, which uses fingers to
pick up objects. After the age of one, children slowly begin to use utensils to handle their food. Unbreakable dishes and cups are
essential, since very young children may play with them or throw them when they become bored with their food.

Food Allergies
Food allergies impact four to six percent of young children in America. Common food allergens include peanuts, eggs, shellfish,
wheat, and cow’s milk. However, lactating women should not make any changes to their diets. Research shows that nursing
mothers who attempt to ward off allergies in their infants by eliminating certain foods may do more harm than good. According to
the American Academy of Allergy, Asthma, and Immunology, mothers who avoided certain dairy products showed decreased levels
in their breast milk of an immunoglobulin specific to cow’s milk. This antibody is thought to protect against the development of
allergies in children. Even when an infant is at higher risk for food allergies, there is no evidence that alterations in a mother’s diet
make a difference. And, it is possible that continuing breastfeeding when introducing solid foods in the infant diet may help prevent
allergies. There is currently no scientific evidence indicating that delayed (after six months of age) or early (before four months of
age) introduction of solid foods is preventative. However, there is evidence that introduction of solid foods after 17 weeks of age is
associated with decreased risk of developing food allergies.[25][26] A landmark study done in 2015 showed that infants with

14.3.15 [Link]
increased risk for allergy to peanuts (severe eczema and/or egg allergy) had a much lower incidence of peanut allergy if very small
amounts (2 grams) were consumed 3 times a week beginning between 4-6 months of age rather than avoided until 60 months of
age.[27] Because of this study, doctors now advise parents of children with a significant family history of allergies to introduce
peanut protein between 4-6 months of age after the infant has begun eating other solid foods.

Early Childhood Caries

Primary teeth are at risk for a disorder known as early childhood caries from breast milk, formula, juice, or other drinks fed through
a bottle. Liquids can build up in a baby’s mouth, and the natural or added sugars lead to decay. Early childhood caries are caused
not only by the kinds of liquids given to an infant, but also by the frequency and length of time that fluids are given. Giving a child
a bottle of juice or other sweet liquids several times each day, or letting a baby suck on a bottle longer than a mealtime, either when
awake or asleep, can also cause early childhood caries. In addition, this practice affects the development and position of the teeth
and the jaw. The risk of early childhood caries continues into the toddler years as children begin to consume more foods with a high
sugar content. Therefore, parents should avoid putting their children to bed with a bottle, and giving their children sugary snacks
and beverages. If a parent insists on giving their child a bottle in bed, then it should be filled with water only.

Newborn Jaundice
Newborn jaundice is a common occurrence in the first few weeks after birth. This condition can occur within a few days of birth
and is characterized by yellowed skin or yellowing in the whites of the eyes, which can be harder to detect in dark-skinned babies.
Jaundice typically appears on the face first, followed by the chest, abdomen, arms, and legs. This condition is caused by elevated
levels of bilirubin in a baby’s bloodstream.

Figure : Image by Centers for Disease Control and Prevention / Public Domain
Bilirubin is a substance created by the breakdown of red blood cells and is removed by the liver. Jaundice develops when a
newborn’s liver does not efficiently remove bilirubin from the blood. There are several types of jaundice associated with newborns:
Physiologic jaundice. The most common type of newborn jaundice and can affect up to 60 percent of full-term babies in the
first week of life.
Breast-milk jaundice. The name for a condition that persists after physiologic jaundice subsides in otherwise healthy babies and
can last for three to twelve weeks after birth. Breast-milk jaundice tends to be genetic and there is no known cause, although it
may be linked to a substance in the breast milk that blocks the breakdown of bilirubin. However, that does not mean
breastfeeding should be stopped. As long as bilirubin levels are monitored, the disorder rarely leads to serious complications.
“Inadequate breastfeeding jaundice”. Occurs when an infant does not get enough milk. This may happen because a newborn
does not get a good start breastfeeding, does not latch on to the mother’s breast properly, or is given other substances that
interfere with breastfeeding (such as juice). Treatment includes increased feedings, with help from a lactation consultant to
ensure that the baby takes in adequate amounts.

14.3.16 [Link]
Newborn jaundice is more common in a breastfed baby and tends to last a bit longer. If jaundice is suspected, a pediatrician will
run blood tests to measure the amount of bilirubin in an infant’s blood. Treatment often involves increasing the number of feedings
to increase bowel movements, which helps to excrete bilirubin. Within a few weeks, as the baby begins to mature and red blood
cell levels diminish, jaundice typically subsides with no lingering effects.[28]

References
1. U.S. Centers for Disease Control. (2018). Breastfeeding report card United States, 2018.
[Link]
2. U.S. Centers for Disease Control. (2018). Breastfeeding report card United States, 2018.
[Link]
3. US Department of Health and Human Services. (2011, January 20). Executive summary: The Surgeon General’s call to action
to support [Link]://[Link]/topics/breastfeeding/[Link]↵
4. Baby-Friendly USA. (2020). The ten steps to successful breastfeeding. [Link]
guidelines/10-steps-and-international-code/↵
5. US Department of Health and Human Services. (2011, January 20). Executive summary: The Surgeon General’s call to action
to support [Link]://[Link]/topics/breastfeeding/[Link]↵
6. US Legal, Inc. (2019). Hawaii. [Link]
7. Hawaiʻi State Judiciary. (2020). Jury service frequently asked questions.
[Link]
8. McMillan B. (2008). Illustrated atlas of the human body. Weldon Owen. ↵
9. World Health Organization. (2019). Promoting proper feeding for infants and young children.
[Link]
10. Food and Nutrition Board, Institute of Medicine. (2005). Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty
acids, cholesterol, protein, and amino acids. The National Academies Press. ↵
11. Ballard, O., & Morrow, A. L. (2013). Human milk composition: nutrients and bioactive factors. Pediatric clinics of North
America, 60(1), 49–74. ↵
12. UNICEF Data. (2019, October). Infant and young child feeding. [Link]
feeding/↵
13. UNICEF. For every child, breastfeeding. [Link]
14. FAO, IFAD, UNICEF, WFP and WHO. (2019). The state of food security and nutrition in the world 2019.
[Link]
15. King J. (2007). Contraception and lactation: Physiology of lactation. Journal of Midwifery and Women’s Health, 52(6), 614–20.
↵
16. American Pregnancy Association. (2019, October 14). Breastfeeding: Overview.
[Link]/firstyearoflife/[Link]. ↵
17. American Pregnancy Association. (2019, October 14). Breastfeeding: Overview.
[Link]/firstyearoflife/[Link]. ↵
18. American Pregnancy Association. (2019, October 14). Breastfeeding: Overview.
[Link]/firstyearoflife/[Link]. ↵
19. LaFleur, E. (2019, July 3). Breast-feeding and alcohol: Is it okay to drink?. Mayo Clinic. [Link]/health/breast-
feeding-and-alcohol/AN02131. ↵
20. American Academy of Pediatrics. (2016, August 8). Breastfeeding benefits your baby’s immune system.
[Link]
[Link]↵
21. National Cancer Institute. (2016, November 9). Reproductive history and breast cancer risk.
[Link] ↵
22. UNICEF. The baby-friendly hospital initiative. [Link]
23. World Health Organization. (2020, April 1). Infant and young child feeding.
[Link]
24. Genetics Home Reference. (2020, June 9) Galactosemia. [Link]

14.3.17 [Link]
25. Alvisi P, Brusa S, Alboresi S. (2015). Recommendations on complementary feeding for healthy, full-term infants. Italian
Journal of Pediatrics, 41(36) [Link] ↵
26. Gever J. (2012, March 7). Nursing mom’s diet no guard against baby allergies. Medpage Today.
[Link]
27. Du Toit G, et al. (2015). Randomized trial of peanut consumption in infants at risk for peanut allergy. New England Journal of
Medicine. 372(9), 803-813. ↵
28. American Pregnancy Association. Breastfeeding and jaundice.
[Link]

This page titled 14.3: Infancy is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper, Marie
Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.
13.3: Infancy by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original source:
[Link]

14.3.18 [Link]
14.4: Toddler Years
Major physiological changes continue into the toddler years. Unlike in infancy, the limbs grow much faster than the trunk, which
gives the body a more proportionate appearance. By the end of the third year, a toddler is taller and more slender than an infant,
with a more erect posture. As the child grows, bone density increases and bone tissue gradually replaces cartilage. This process
known as ossification is not completed until puberty.[1]

Figure : Image by kazuend on [Link] / CC0

Developmental milestones include running, drawing, toilet training, and self-feeding. How a toddler acts, speaks, learns, and eats
offers important clues about their development. By the age of two, children have advanced from infancy and are on their way to
becoming school-aged children. Their physical growth and motor development slows compared to the progress they made as
infants. However, toddlers experience enormous intellectual, emotional, and social changes. Of course, food and nutrition continue
to play an important role in a child’s development. During this stage, the diet completely shifts from breastfeeding or bottle-feeding
to solid foods along with healthy juices and other liquids. Parents of toddlers also need to be mindful of certain nutrition-related
issues that may crop up during this stage of the human life cycle. For example, fluid requirements relative to body size are higher in
toddlers than in adults because children are at greater risk of dehydration.
The toddler years pose interesting challenges for parents or other caregivers, as children learn how to eat on their own and begin to
develop personal preferences. However, with the proper diet and guidance, toddlers can continue to grow and develop at a healthy
rate.

Nutritional Requirements
MyPlate may be used as a guide for the toddler’s diet ([Link]/[Link]). A toddler’s serving sizes
should be approximately one-quarter that of an adult’s. One way to estimate serving sizes for young children is one tablespoon for
each year of life. For example, a two-year-old child would be served 2 tablespoons of fruits or vegetables at a meal, while a four-
year-old would be given 4 tablespoons, or a quarter cup. Here is an example of a toddler-sized meal:
1 ounce of meat or chicken, or 2 to 3 tablespoons of beans
One-quarter slice of whole-grain bread
1 to 2 tablespoons of cooked vegetable
1 to 2 tablespoons of fruit

Energy
The energy requirements for ages two to three are about 1,000 to 1,400 calories a day. In general, a toddler needs to consume about
40 calories for every inch of height. For example, a young child who measures 32 inches should take in an average of 1,300
calories a day. However, the recommended caloric intake varies with each child’s level of activity. Toddlers require small, frequent,
nutritious snacks and meals to satisfy energy requirements. The amount of food a toddler needs from each food group depends on
daily calorie needs. See Table for some examples.

14.4.1 [Link]
 Table : Serving Sizes for Toddlers

Food Group Daily Serving Examples

3 slices of bread
About 3-5 ounces of grains per day, ideally 1 slice of bread, plus ⅓ cup of cereal,
Grains
whole grains and ¼ cup of cooked whole-grain rice
or pasta
1 ounce of lean meat or chicken, plus
2-4 ounces of meat, poultry, fish, eggs, or one egg
Proteins
legumes 1 ounce of fish, plus ¼ cup of cooked
beans

1 small apple cut into slices

1-1.5 cups of fresh, frozen, canned, and/or
Fruits 1 cup of sliced or cubed fruit
dried fruits, or 100 percent fruit juice
1 large banana
1 cup of pureed, mashed, or finely
chopped vegetables (such as sweet
Vegetables 1-1.5 cups of raw and/or cooked vegetables
potato, chopped broccoli, or tomato
sauce)
2 cups of fat-free or low-fat milk
1 cup of fat-free or low-fat milk, plus 2
Dairy Products 2-2.5 cups per day slices of cheese
1 cup of fat-free or low-fat milk, plus 1
cup of yogurt

Source: Hayes, D. (2018, February 20). It‘s about eating right: Size-wise nutrition for toddlers. Academy of Nutrition and
Dietetics. [Link]

Macronutrients
For carbohydrate intake, the Acceptable Macronutrient Distribution Range (AMDR) is 45 to 65 percent of daily calories (113 to
163 grams for 1,000 daily calories). Toddlers’ needs increase to support their body and brain development. The RDA of protein is 5
to 20 percent of daily calories (13 to 50 grams for 1,000 daily calories). The AMDR for fat for toddlers is 30 to 40 percent of daily
calories (33 to 44 grams for 1,000 daily calories). Essential fatty acids are vital for the development of the eyes, along with nerve
and other types of tissue. However, toddlers should not consume foods with high amounts of trans fats and saturated fats. Instead,
young children require the equivalent of 3 teaspoons of healthy oils, such as canola oil, each day.

Micronutrients
As a child grows bigger, the demands for micronutrients increase. These needs for vitamins and minerals can be met with a
balanced diet, with a few exceptions. According to the American Academy of Pediatrics, toddlers and children of all ages need 600
international units of vitamin D per day. Vitamin D-fortified milk and cereals can help to meet this need. However, toddlers who do
not get enough of this micronutrient should receive a supplement. Pediatricians may also prescribe a fluoride supplement for
toddlers who live in areas with fluoride-poor water. Iron deficiency is also a major concern for children between the ages of two
and three. You will learn about iron-deficiency anemia later in this section.

Learning How to Handle Food

As children grow older, they enjoy taking care of themselves, which includes self-feeding. During this phase, it is important to offer
children foods that they can handle on their own and that help them avoid choking and other hazards. Examples include fresh fruits
that have been sliced into pieces, orange or grapefruit sections, peas or potatoes that have been mashed for safety, a cup of yogurt,
and whole-grain bread or bagels cut into pieces. Even with careful preparation and training, the learning process can be messy. As a
result, parents and other caregivers can help children learn how to feed themselves by providing the following:

14.4.2 [Link]
 small utensils that fit a young child’s hand
small cups that will not tip over easily
plates with edges to prevent food from falling off
small servings on a plate
high chairs, booster seats, or cushions to reach a table

Feeding Problems in the Toddler Years

During the toddler years, parents may face a number of problems related to food and nutrition. Possible obstacles include difficulty
helping a young child overcome a fear of new foods, or fights over messy habits at the dinner table. Even in the face of problems
and confrontations, parents and other caregivers must make sure their preschooler has nutritious choices at every meal. For
example, even if a child stubbornly resists eating vegetables, parents should continue to provide them. Before long, the child may
change their mind, and develop a taste for foods once abhorred. It is important to remember this is the time to establish or reinforce
healthy habits.
Nutritionist Ellyn Satter states that feeding is a responsibility that is split between parent and child. According to Satter, parents are
responsible for what their infants eat, while infants are responsible for how much they eat. In the toddler years and beyond, parents
are responsible for what they offer their children to eat, when they eat, and where they eat, while children are responsible for how
much food they eat and whether they eat. Satter states that the role of a parent or a caregiver in feeding includes the following:
selecting and preparing food
providing regular meals and snacks
making mealtimes pleasant
showing children what they must learn about mealtime behavior
avoiding letting children eat in between meal- or snack-times[2]

Picky Eaters
The parents of toddlers are likely to notice a sharp drop in their child’s appetite. Children at this stage are often picky about what
they want to eat because they just aren’t as hungry. They may turn their heads away after eating just a few bites. Or, they may resist
coming to the table at mealtimes. They also can be unpredictable about what they want to consume for specific meals or at
particular times of the day. Although it may seem as if toddlers should increase their food intake to match their level of activity,
there is a good reason for picky eating. A child’s growth rate slows after infancy, and toddlers ages two and three do not require as
much food.
One way to encourage a picky eater to try healthy foods is to get them involved in age-appropriate tasks in meal preparation. Even
small toddlers can tear up lettuce leaves for a salad, or arrange fruit and cheese slices on a plate. Keiki Can Cook! is an online
Hawai‘i cookbook with healthy recipes for children that highlights tasks for young children. It can be found at:
[Link]

Toddler Obesity
Another potential problem during the early childhood years is toddler obesity. According to the US Department of Health and
Human Services, in the past thirty years, obesity rates have more than doubled for all children, including infants and toddlers.[3]
Almost 10 percent of infants and toddlers weigh more than they should considering their length, and slightly more than 20 percent
of children ages two to five are overweight or have obesity.[4]
Some minority group children, such as Filipinos, Native Hawaiians, and Other Pacific Islanders, in Hawai‘i have higher rates of
overweight and obesity. In 2012, 12.8% of Hawai‘i WIC (low-income) participants ages two to four years were overweight and
10.2% had obesity.[5][6][7] One study that investigated 2000-2010 data for children ages two to eight years in 51 communities in 11
United States Affiliated Pacific (USAP) jurisdictions found that 14.4% of the study population was overweight and 14% had
obesity.[8]
Obesity during early childhood tends to linger as a child matures and cause health problems later in life. There are a number of
reasons for this growing problem. One is a lack of time. Parents and other caregivers who are constantly on the go may find it
difficult to fit home-cooked meals into a busy schedule and may turn to fast food and other conveniences that are quick and easy,

14.4.3 [Link]
but not nutritionally sound. Another contributing factor is a lack of access to fresh fruits and vegetables. This is a problem
particularly in low-income neighborhoods where local stores and markets may not stock fresh produce or may have limited options.
Physical inactivity is also a factor, as toddlers who live a sedentary lifestyle are more likely to be overweight or obese. Another
contributor is a lack of breastfeeding support. Children who were breastfed as infants have lower rates of obesity than children who
were bottle-fed.
To prevent or address toddler obesity parents and caregivers can do the following:
Eat at the kitchen table instead of in front of a television to monitor what and how much a child eats.
Offer a child healthy portions. The size of a toddler’s fist is an appropriate serving size.
Plan time for physical activity, about sixty minutes or more per day. Toddlers should have no more than sixty minutes of
sedentary activity, such as watching television, per day.

Early Childhood Caries

Early childhood caries remain a potential problem during the toddler years. The risk of early childhood caries continues as children
begin to consume more foods with a high sugar content. According to the National Health and Nutrition Examination Survey,
children between ages of two and five consume about 200 calories of added sugar per day.[9] Therefore, parents with toddlers
should avoid processed foods, such as snacks from vending machines, and sugary beverages, such as soda. Parents also need to
instruct a child on brushing their teeth at this time to help a toddler develop healthy habits and avoid tooth decay. Generally,
children need help brushing their teeth until they are 5 years old.

Iron-Deficiency Anemia
An infant who switches to solid foods, but does not eat enough iron-rich foods, can develop iron-deficiency anemia. This condition
occurs when an iron-deprived body cannot produce enough hemoglobin, a protein in red blood cells that transports oxygen
throughout the body. The inadequate supply of hemoglobin for new blood cells results in anemia. Iron-deficiency anemia causes a
number of problems including weakness, pale skin, shortness of breath, and irritability. It can also result in intellectual, behavioral,
or motor problems. In infants and toddlers, iron-deficiency anemia can occur as young children are weaned from iron-rich foods,
such as breast milk and iron-fortified formula. They begin to eat solid foods that may not provide enough of this nutrient. As a
result, their iron stores become diminished at a time when this nutrient is critical for brain growth and development.
There are steps that parents and caregivers can take to prevent iron-deficiency anemia, such as adding more iron-rich foods to a
child’s diet, including lean meats, fish, poultry, eggs, legumes, and iron-enriched whole-grain breads and cereals. A toddler’s diet
should provide 7 to 10 milligrams of iron daily. Although milk is critical for the bone-building calcium that it provides, intake
should not exceed the RDA to avoid displacing foods rich with iron. Children may also be given a daily supplement, using infant
vitamin drops with iron or ferrous sulfate drops. If iron-deficiency anemia does occur, treatment includes a dosage of 3 milligrams
per kilogram once daily before breakfast, usually in the form of a ferrous sulfate syrup. Consuming vitamin C, such as orange juice,
can also help to improve iron absorption.[10]

References
1. Polan, E., & Taylor, D. (2003). Journey across the life span: Human development and health promotion. F.A. Davis Co. ↵
2. Satter, E. (2016). Ellyn Satter’s division of responsibility in feeding. [Link]
content/uploads/2016/11/[Link]↵
3. Ogden, C., & Carroll, M. (2010, June). Prevalence of obesity among children and adolescents: United States, trends 1963-1965
through 2007-2008. Centers for Disease Control and Prevention.
[Link]
4. Institute of Medicine. (2011). Early childhood obesity prevention policies . The National Academies Press. ↵
5. Oshiro C., Novotny R., Grove J., Hurwitz E. (2015). Race/ethnic differences in birth size, infant growth, and body mass index
at age five years in children in Hawaii. Childhood Obesity, 11(6),683-690. [Link]
6. Thorn B., Tadler C., Huret N., Ayo E., Trippe C. (2015, November). WIC participant and program characteristics final report.
[Link]
7. State of childhood obesity. Obesity rates & trend data. [Link]

14.4.4 [Link]
 8. Novotny R., Fenfang L., Fialkowski, M. (2016). Prevalence of obesity and acanthosis nigricans among young children in the
Children’s Healthy Living Program in the United States Affiliated Pacific. Medicine, 37, e4711. [Link]
content/up....-[Link] ↵
9. Ervin, R. B., Kit, B. K., Carroll, M. D., & Ogden, C. L. (2012). Consumption of added sugar among U.S. children and
adolescents, 2005-2008. NCHS data brief, (87), 1–8. ↵
10. Louis A., Kazal J.R. (2002). Prevention of Iron deficiency in infants and toddlers. American Academy of Family Physicians,
66(7), 1217—25. [Link] ↵

This page titled 14.4: Toddler Years is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Jennifer Draper,
Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts platform.
13.4: Toddler Years by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original source:
[Link]

14.4.5 [Link]
 CHAPTER OVERVIEW

15: Lifespan Nutrition in Adulthood

Learning Objectives
By the end of this chapter you will be able to:
Describe the physiological basis for nutrient requirements during adulthood.

15.1: Introduction to Lifespan Nutrition in Adulthood

15.2: Young Adulthood
15.3: Middle Age
15.4: Older Adulthood- The Golden Years

This page titled 15: Lifespan Nutrition in Adulthood is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by
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LibreTexts platform.

1
15.1: Introduction to Lifespan Nutrition in Adulthood
E ola koa.
Live like a koa tree.

Image by [Link] on [Link] / CCO

Adulthood begins at the end of adolescents and continues until the end of one’s life. During adulthood, the human body will reach
maximum cardiac output specifically between ages twenty and thirty. Bone and muscle mass also reach optimal levels, and
physical activity helps to improve muscle strength, endurance, and tone.[1] In order to maintain health and fitness throughout the
lifespan, it is important to remain active. The CDC has implemented science based physical activity guidelines for all Americans to
follow in hopes of creating a healthy lifestyle. In Hawai‘i, nearly 60% of all adults meet the recommended aerobic physical activity
guidelines. However, only 32% of adults meet the guidelines for muscle strengthening and less than a quarter (23%) of Hawai‘i
residents meet the recommended guidelines for both.[2] To learn more about the current physical activity guidelines visit
[Link]/cancer/dcpc/prevention/policies_practices/physical_activity/[Link].
Along with physical activity, nutrition also plays an essential role in maintaining health through adulthood. As you’ve already
learned, a healthful diet includes a variety of nutrient dense foods. The USDA Dietary Guidelines recommend eating a balanced
diet from the five food groups: fruits, vegetables, protein, grains and dairy.[3] In Hawai‘i, only about 19% of adults eat the
recommended amount of servings of fruits and vegetables per day. Inadequacy of any food group can lead to several health issues.
[4]
Consuming diets high in fruits and vegetables may have health benefits such as a reduced risk for heart disease, and protection
against certain cancers.[5]
1. Polan EU, Taylor DR. (2003). Journey Across the LifeSpan: Human Development and Health Promotion. Philadelphia: F. A.
Davis Company, 192–93. ↵
2. Hawaii Physical Activity and Nutrition Plan, 2013-2020. [Link]
nutrition/files/2013/08/[Link]. Accessed February 16, 2018. ↵
3. All About the Fruit Group. USDA [Link]. [Link] Accessed February 16, 2018. ↵
4. Hawai‘i Physical Activity and Nutrition Plan, 2013-2020. [Link]
nutrition/files/2013/08/[Link]. Accessed February 16, 2018. ↵
5. Nutrients and Health Benefits. USDA [Link]. [Link] Accessed
February 16, 2018. ↵

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and/or curated by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and
standards of the LibreTexts platform.
15.1: Introduction to Lifespan Nutrition in Adulthood by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed
CC BY-NC-SA 4.0. Original source: [Link]

15.1.1 [Link]
15.2: Young Adulthood
Young adulthood is the period from ages nineteen to thirty years. It is a stable time compared to childhood and adolescence.
Physical growth has been completed and all of the organs and body systems are fully developed. Typically, a young adult who is
active has reached his or her physical peak and is in prime health. For example, vital capacity, or the maximum amount of air that
the lungs can inhale and exhale, is at its peak between the ages of twenty and forty.[1] During this life stage, it important to continue
to practice good nutrition. Healthy eating habits promote metabolic functioning, assist repair and regeneration, and prevent the
development of chronic conditions. In addition, the goals of a young adult, such as beginning a career or seeking out romantic
relationships, can be supported with good habits. Proper nutrition and adequate physical activity at this stage not only promote
wellness in the present, but also provide a solid foundation for the future.

Figure : Image by David Marcu on [Link] / CC0

With the onset of adulthood, good nutrition can help young adults enjoy an active lifestyle. The body of an adult does not need to
devote its energy and resources to support the rapid growth and development that characterizes youth. However, the choices made
during those formative years can have a lasting impact. Eating habits and preferences developed during childhood and adolescence
influence health and fitness into adulthood. Some adults have gotten a healthy start and have established a sound diet and regular
activity program, which helps them remain in good condition from young adulthood into the later years. Others carry childhood
obesity into adulthood, which adversely affects their health. However, it is not too late to change course and develop healthier
habits and lifestyle choices. Therefore, adults must monitor their dietary decisions and make sure their caloric intake provides the
energy that they require, without going into excess.

Energy and Macronutrients

Young men typically have higher nutrient needs than young women. For ages nineteen to thirty, the energy requirements for
women are 1,800 to 2,400 calories, and 2,400 to 3,000 calories for men, depending on activity level. These estimates do not include
women who are pregnant or breastfeeding, who require a higher energy intake. For carbohydrates, the AMDR is 45 to 65 percent of
daily calories. All adults, young and old, should eat fewer energy-dense carbohydrates, especially refined, sugar-dense sources,
particularly for those who lead a more sedentary lifestyle. The AMDR for protein is 10 to 35 percent of total daily calories, and
should include a variety of lean meat and poultry, eggs, beans, peas, nuts, and seeds. The guidelines also recommend that adults eat
two 4-ounce servings (or one 8-ounce serving) of seafood per week.
It is also important to replace proteins that are high in trans fats and saturated fat with ones that are lower in solid fats and calories.
All adults should limit total fat to 20 to 35 percent of their daily calories and keep saturated fatty acids to less than 10 percent of
total calories by replacing them with monounsaturated and polyunsaturated fatty acids. Avoid trans fats by limiting foods that
contain synthetic sources, such as partially hydrogenated oils. The AMDR for fiber is 22 to 28 grams per day for women and 28 to
34 grams per day for men. Soluble fiber may help improve cholesterol and blood sugar levels, while insoluble fiber can help
prevent constipation.

15.2.1 [Link]
Micronutrients
Micronutrient needs in adults differ slightly according to sex. Young men and women who are very athletic and perspire a great
deal also require extra sodium, potassium, and magnesium. Males require more of vitamins C and K, along with thiamine,
riboflavin, and niacin. Females require extra iron due to menstruation. Therefore, it can be beneficial for some young adults to
follow a daily multivitamin regimen to help meet nutrient needs. But as always, it is important to remember “food first,
supplements second.” Table shows the micronutrient recommendations for adult men and women.
Table : Micronutrient Levels during Adulthood

Nutrient Adult Males Adult Females

Vitamin A (mcg) 900.0 700.0

Vitamin B6 (mg) 1.3 1.3

Vitamin B12 (mcg) 2.4 2.4

Vitamin C (mg) 90.0 75.0

Vitamin D (mcg) 5.0 5.0

Vitamin E (mg) 15.0 15.0

Vitamin K(mcg) 120.0 90.0

Calcium (mg) 1,000.0 1,000.0

Folate (mcg) 400.0 400.0

Iron (mg) 8.0 18.0

Magnesium (mg) 400.0 310.0

Niacin (mg) 16.0 14.0

Phosphorus (mg) 700.0 700.0

Riboflavin (mg) 1.3 1.1

Selenium 55.0 55.0

Thiamin (mg) 1.2 1.1

Zinc (mg) 11.0 8.0

Source: Institute of Medicine. 2006. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC:
The National Academies Press. [Link] Accessed December 10, 2017.

Nutritional Concerns in Young Adulthood

There are a number of intake recommendations for young adults. According to the IOM, an adequate intake (AI) of fluids for men
is 3.7 liters per day, from both food and liquids. The AI for women is 2.7 liters per day, from food and liquids.[2] It is best when
fluid intake is from water, instead of sugary beverages, such as soda. Fresh fruits and vegetables, including watermelon and
cucumbers, are excellent food sources of fluid. In addition, young adults should avoid consuming excessive amounts of sodium.
The health consequences of high sodium intake include high blood pressure and its complications. Therefore, it is best to limit
sodium to less than 2,300 milligrams per day.

Obesity during Adulthood

Obesity remains a major concern into young adulthood. For adults, a BMI above 25 is considered overweight, and a BMI of 30 or
higher is obese. By that measurement, about two-thirds of all adults in the United States are overweight or obese, with 35.7 percent

15.2.2 [Link]
considered to be obese. [3] As during childhood and adolescence, physical inactivity and poor dietary choices are major contributors
to obesity in adulthood. Solid fats, alcohol, and added sugars (SoFAAS) make up 35 percent of total calories for most people,
leading to high levels of saturated fat and cholesterol and insufficient dietary fiber. Therefore, it is important to limit unrefined
carbohydrates and processed foods.

References
1. Polan EU, Taylor DR. (2003). Journey Across the Life Span: Human Development and Health Promotion. Philadelphia: F. A.
Davis Company, 192–93. ↵
2. Institute of Medicine. 2005. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, DC:
The National Academies Press. [Link] Accessed December 10, 2017. ↵
3. Prevalence of Obesity in the United States, 2009–2010. Centers for Disease Control, National Center for Health
[Link] Data Brief, No. 82. [Link] Published January 2012. Accessed
December 8, 2017. ↵

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Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the LibreTexts
platform.
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source: [Link]

15.2.3 [Link]
15.3: Middle Age
Middle age is defined as the period from age thirty-one to fifty. The early period of this stage is very different from the end. For
example, during the early years of middle age, many women experience pregnancy, childbirth, and lactation. In the latter part of
this life stage, women face perimenopause, which is a transition period that leads up to menopause, or the end of menstruation. A
number of physical changes take place in the middle-aged years, including the loss of bone mass in women due to dropping levels
of estrogen during menopause. In both men and women, visual acuity declines, and by age forty there can be a decreased ability to
see objects at a close distance, a condition known as presbyopia.[1] All of these are signs of aging, as the human body begins to
change in subtle and not-so-subtle ways. However, a middle aged person can remain vital, healthy, and near his or her physical
peak with proper diet and adequate exercise.
During this stage of the human life cycle, adults begin to experience the first outward signs of aging. Wrinkles begin to appear,
joints ache after a highly active day, and body fat accumulates. There is also a loss of muscle tone and elasticity in the connective
tissue.[2] Many people in their late thirties and in their forties notice a decline in endurance, the onset of wear-and-tear injuries
(such as osteoarthritis), and changes in the digestive system. Wounds and other injuries also take longer to heal. Body composition
changes due to fat deposits in the trunk. To maintain health and wellness during the middle-aged years and beyond, it is important
to:
maintain a healthy body weight
consume nutrient-dense foods
drink alcohol moderately or not at all
be a nonsmoker
engage in moderate physical activity at least 150 minutes per week

Energy and Macronutrients

The energy requirements for ages thirty-one to fifty are 1,800 to 2,200 calories for women and 2,200 to 3,000 calories for men,
depending on activity level. These estimates do not include women who are pregnant or breastfeeding. Middle-aged adults must
rely on healthy food sources to meet these needs. In many parts of North America, typical dietary patterns do not match the
recommended guidelines. For example, five foods—iceberg lettuce, frozen potatoes, fresh potatoes, potato chips, and canned
tomatoes—account for over half of all vegetable intake.[3] Following the dietary guidelines in the middle-aged years provides
adequate but not excessive energy, macronutrients, vitamins, and minerals.
The AMDRs for carbohydrates, protein, fat, fiber, and fluids remain the same from young adulthood into middle age. It is important
to avoid putting on excess pounds and limiting an intake of SoFAAS to help avoid cardiovascular disease, diabetes, and other
chronic conditions.

Micronutrients
There are some differences, however, regarding micronutrients. For men, the recommendation for magnesium increases to 420
milligrams daily, while middle-aged women should increase their intake of magnesium to 320 milligrams per day. Other key
vitamins needed during the middle-aged years include folate and vitamins B6 and B12 to prevent elevation of homocysteine, a
byproduct of metabolism that can damage arterial walls and lead to atherosclerosis, a cardiovascular condition. Again, it is
important to meet nutrient needs with food first, then supplementation, such as a daily multivitamin, if you can’t meet your needs
through food.

Preventive/Defensive Nutrition
During the middle-aged years, preventive nutrition can promote wellness and help organ systems to function optimally throughout
aging. Preventive nutrition is defined as dietary practices directed toward reducing disease and promoting health and well-being.
Healthy eating in general—such as eating unrefined carbohydrates instead of refined carbohydrates and avoiding trans fats and
saturated fats—helps to promote wellness. However, there are also some things that people can do to target specific concerns. One
example is consuming foods high in antioxidants, such as strawberries, blueberries, and other colorful fruits and vegetables, to
reduce the risk of cancer.

15.3.1 [Link]
Phytochemicals are also great nonessential nutrients that may promote body [Link] example, carotenoids, which are found in
carrots, cantaloupes, sweet potatoes, and butternut squash, may protect against cardiovascular disease by helping to prevent the
oxidation of cholesterol in the arteries, although research is ongoing.[4] According to the American Cancer Society, some studies
suggest that a phytochemical found in watermelons and tomatoes called lycopene may protect against stomach, lung, and prostate
cancer, although more research is needed.[5]
Omega-3 fatty acids can help to prevent coronary artery disease. These crucial nutrients are found in oily fish, including salmon,
mackerel, tuna, herring, cod, and halibut. Other beneficial fats that are vital for healthy functioning include monounsaturated fats,
which are found in plant oils, avocados, peanuts, and pecans.

Menopause
In the middle-aged years, women undergo a specific change that has a major effect on their health. They begin the process of
menopause, typically in their late forties or early fifties. The ovaries slowly cease to produce estrogen and progesterone, which
results in the end of menstruation. Menopausal symptoms can vary, but often include hot flashes, night sweats, and mood changes.
The hormonal changes that occur during menopause can lead to a number of physiological changes as well, including alterations in
body composition, such as weight gain in the abdominal area. Bone loss is another common condition related to menopause due to
the loss of female reproductive hormones. Bone thinning increases the risk of fractures, which can affect mobility and the ability to
complete everyday tasks, such as cooking, bathing, and dressing.[6]
Recommendations for women experiencing menopause or perimenopause (the stage just prior to the end of the menstruation)
include:
consuming a variety of whole grains, and other nutrient-dense foods
maintaining a diet high in fiber, low in fat, and low in sodium
avoiding caffeine, spicy foods, and alcohol to help prevent hot flashes
eating foods rich in calcium, or taking physician-prescribed calcium supplements and vitamin D
doing stretching exercises to improve balance and flexibility and reduce the risk of falls and fractures

References
1. Polan EU, Taylor DR. (2003). Journey Across the Life Span: Human Development and Health Promotion. Philadelphia: F. A.
Davis Company, 192–93. ↵
2. Polan EU, Taylor DR. (2003), Journey Across the Life Span: Human Development and Health Promotion. Philadelphia: F. A.
Davis Company, 212–213. ↵
3. Drewnowski A, Darmon, N. (2005). Food Choices and Diet Cost: an Economic Analysis. The Journal of Nutrition, 135(4), 900-
904. [Link]/content/135/4/[Link]. Accessed December 12, 2017. ↵
4. Voutilainen S, Nurmi T, Mursu J, Rissanen, TH. (2006). Carotenoids and Cardiovascular Health. American Journals of Clinical
Nutrition, 83, 1265–71. [Link]/content/83/6/[Link]. Accessed December 9, 2017. ↵
5. Lycopene. American Cancer Society.
[Link]
e. Updated May 13, 2010. Accessed November 29, 2017. ↵
6. Eating Right During [Link] of Nutrition and Dietetics. [Link]/Public/[Link]?id=6809. Updated
January 2015. Accessed December 4, 2017. ↵

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15.3: Middle Age by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-SA 4.0. Original source:
[Link]

15.3.2 [Link]
15.4: Older Adulthood- The Golden Years
The senior years are the period from age fifty-one until the end of life. A number of physiological and emotional changes take place
during this life stage. For example, many older adults face serious health challenges, such as cancer, heart disease, diabetes, or
dementia. Both men and women experience a loss of hormone production, muscle mass, and strength and undergo changes in body
composition. Fat deposits build up in the abdominal area, which increases the risk for Type 2 diabetes and cardiovascular disease.
The skin becomes thinner and may take longer to heal after an injury. Around age seventy, men begin to experience bone loss when
estrogen and testosterone levels begin to decline.[1] Also in the later years, the heart has to work harder because each pump is not as
efficient as it used to be. Kidneys are not as effective in excreting metabolic products such as sodium, acid, and potassium, which
can alter water balance and increase the risk for over- or underhydration. In addition, immune function decreases and there is lower
efficiency in the absorption of vitamins and minerals.

Figure : “Man wearing blue shirt

standing on white surfboard” by Alex Blajan / Unsplash License
In addition, disorders of the nervous system can have profound effects. Dementia is the umbrella term for changes in the normal
activity of the brain. Elderly adults who suffer from dementia may experience memory loss, agitation, and delusions. One in eight
people over age sixty-four and almost half of all people over eighty-five suffer from the brain disorder Alzheimer’s disease, which
is the most common form of dementia.[2] Neurological disorder and psychological conditions, such as depression, can influence
attitudes toward food, along with the ability to prepare or ingest food. They might lead some adults to overindulge to compensate
for stress or emotions that are difficult to handle. Other adults might eat less or pay less attention to their diet and nutritional needs.
Older adults may also need guidance from dietitians and health-care professionals to make the best dietary choices for this stage of
life.
Beginning at age fifty-one, requirements change once again and relate to the nutritional issues and health challenges that older
people face. After age sixty, blood pressure rises and the immune system may have more difficulty battling invaders and infections.
The skin becomes more wrinkled and hair has turned gray or white or fallen out, resulting in hair thinning. Older adults may
gradually lose an inch or two in height. Also, short-term memory might not be as keen as it once was.[3]
Being either underweight or overweight is also a major concern for the elderly. However, many older adults remain in relatively
good health and continue to be active into their golden years. Good nutrition is often the key to maintaining health later in life. In
addition, the fitness and nutritional choices made earlier in life set the stage for continued health and happiness. Older adults should
continue to consume nutrient-dense foods and remain physically active. However, deficiencies are more common after age sixty,
primarily due to reduced intake or malabsorption. The loss of mobility among frail, homebound elderly adults also impacts their
access to healthy, diverse foods.

Energy and Macronutrients

Due to reductions in lean body mass and metabolic rate, older adults require less energy than younger adults. The energy
requirements for people ages fifty-one and over are 1,600 to 2,200 calories for women and 2,000 to 2,800 calories for men,
depending on activity level. The decrease in physical activity that is typical of older adults also influences nutritional requirements.
The AMDRs for carbohydrates, protein, and fat remain the same from middle age into old age. Older adults should substitute more

15.4.1 [Link]
unrefined carbohydrates for refined ones, such as whole grains and brown rice. Fiber is especially important in preventing
constipation and diverticulitis, and may also reduce the risk of colon cancer. Protein should be lean, and healthy fats, such as
omega-3 fatty acids, are part of any good diet.

Micronutrients
An increase in certain micronutrients can help maintain health during this life stage. The recommendations for calcium increase to
1,200 milligrams per day for both men and women to slow bone loss. Also to help protect bones, vitamin D recommendations
increase to 10–15 micrograms per day for men and women. Vitamin B6 recommendations rise to 1.7 milligrams per day for older
men and 1.5 milligrams per day for older women to help lower levels of homocysteine and protect against cardiovascular disease.
As adults age, the production of stomach acid can decrease and lead to an overgrowth of bacteria in the small intestine. This can
affect the absorption of vitamin B12 and cause a deficiency. As a result, older adults need more B12 than younger adults, and require
an intake of 2.4 micrograms per day, which helps promote healthy brain functioning. For elderly women, higher iron levels are no
longer needed postmenopause and recommendations decrease to 8 milligrams per day. People over age fifty should eat foods rich
with all of these micronutrients.

Nutritional Concerns for Older Adults

Dietary choices can help improve health during this life stage and address some of the nutritional concerns that many older adults
face. In addition, there are specific concerns related to nutrition that affect adults in their later years. They include medical
problems, such as disability and disease, which can impact diet and activity level. For example, dental problems can lead to
difficulties with chewing and swallowing, which in turn can make it hard to maintain a healthy diet. The use of dentures or the
preparation of pureed or chopped foods can help solve this problem. There also is a decreased thirst response in the elderly, and the
kidneys have a decreased ability to concentrate urine, both of which can lead to dehydration.

Sensory Issues
At about age sixty, taste buds begin to decrease in size and number. As a result, the taste threshold is higher in older adults,
meaning that more of the same flavor must be present to detect the taste. Many elderly people lose the ability to distinguish
between salty, sour, sweet, and bitter flavors. This can make food seem less appealing and decrease the appetite. An intake of foods
high in sugar and sodium can increase due to an inability to discern those tastes. The sense of smell also decreases, which impacts
attitudes toward food. Sensory issues may also affect the digestion because the taste and smell of food stimulates the secretion of
digestiveenzymesin the mouth, stomach, and pancreas.

Dysphagia
Some older adults have difficulty getting adequate nutrition because of the disorder dysphagia, which impairs the ability to
swallow. Any damage to the parts of the brain that control swallowing can result in dysphagia, therefore stroke is a common cause.
Dysphagia is also associated with advanced dementia because of overall brain function impairment. To assist older adults suffering
from dysphagia, it can be helpful to alter food consistency. For example, solid foods can be pureed, ground, or chopped to allow
more successful and safe swallow. This decreases the risk of aspiration, which occurs when food flows into the respiratory tract and
can result in pneumonia. Typically, speech therapists, physicians, and dietitians work together to determine the appropriate diet for
dysphagia patients.

Obesity in Old Age

Similar to other life stages, obesity is a concern for the elderly. Adults over age sixty are more likely to be obese than young or
middle-aged adults. As explained throughout this chapter, excess body weight has severe consequences. Being overweight or obese
increases the risk for potentially fatal conditions that can afflict the elderly. They include cardiovascular disease, which is the
leading cause of death in the United States, and Type 2 diabetes, which causes about seventy thousand deaths in the United States
annually.[4] Obesity is also a contributing factor for a number of other conditions, including arthritis.
For older adults who are overweight or obese, dietary changes to promote weight loss should be combined with an exercise
program to protect muscle mass. This is because dieting reduces muscle as well as fat, which can exacerbate the loss of muscle
mass due to aging. Although weight loss among the elderly can be beneficial, it is best to be cautious and consult with a healthcare
professional before beginning a weight-loss program.

15.4.2 [Link]
The Anorexia of Aging
In addition to concerns about obesity among senior citizens, being underweight can be a major problem. A condition known as the
anorexia of aging is characterized by poor food intake, which results in dangerous weight loss. This major health problem among
the elderly leads to a higher risk for immune deficiency, frequent falls, muscle loss, and cognitive deficits. Reduced muscle mass
and physical activity mean that older adults need fewer calories per day to maintain a normal weight. It is important for health care
providers to examine the causes for anorexia of aging among their patients, which can vary from one individual to another.
Understanding why some elderly people eat less as they age can help healthcare professionals assess the risk factors associated
with this condition. Decreased intake may be due to disability or the lack of a motivation to eat. Also, many older adults skip at
least one meal each day. As a result, some elderly people are unable to meet even reduced energy needs.
Nutritional interventions should focus primarily on a healthy diet. Remedies can include increasing the frequency of meals and
adding healthy, high-calorie foods (such as nuts, potatoes, whole-grain pasta, and avocados) to the diet. Liquid supplements
between meals may help to improve caloric intake.[5] Health care professionals should consider a patient’s habits and preferences
when developing a nutritional treatment plan. After a plan is in place, patients should be weighed on a weekly basis until they show
improvement.

Vision Problems
Many older people suffer from vision problems and a loss of vision. Age-related macular degeneration is the leading cause of
blindness in Americans over age sixty.[6] This disorder can make food planning and preparation extremely difficult and people who
suffer from it often must depend on caregivers for their meals. Self-feeding also may be difficult if an elderly person cannot see his
or her food clearly. Friends and family members can help older adults with shopping and cooking. Food-assistance programs for
older adults (such as Meals on Wheels) can also be helpful.
Diet may help to prevent macular degeneration. Consuming colorful fruits and vegetables increases the intake of lutein and
zeaxanthin. Several studies have shown that these antioxidants provide protection for the eyes. Lutein and zeaxanthin are found in
green, leafy vegetables such as spinach, kale, and collard greens, and also corn, peaches, squash, broccoli, Brussels sprouts, orange
juice, and honeydew melon.[7]

Longevity and Nutrition

The foods you consume in your younger years influence your health as you age. Good nutrition and regular physical activity can
help you live longer and healthier. Conversely, poor nutrition and a lack of exercise can shorten your life and lead to medical
problems. The right foods provide numerous benefits at every stage of life. They help an infant grow, an adolescent develop
mentally and physically, a young adult achieve his or her physical peak, and an older adult cope with aging. Nutritious foods form
the foundation of a healthy life at every age.

Developing Habits
Eating habits develop early in life. They are typically formed within the first few years and it is believed that they persist for years,
if not for life. So it is important for parents and other caregivers to help children establish healthy habits and avoid problematic
ones. Children begin expressing their preferences at an early age. Parents must find a balance between providing a child with an
opportunity for self-expression, helping a child develop healthy habits, and making sure that a child meets all of their nutritional
needs.
Bad habits and poor nutrition have an accrual effect. The foods you consume in your younger years will impact your health as you
age, from childhood into the later stages of life. As a result, good nutrition today means optimal health tomorrow. Therefore, it is
best to start making healthy choices from a young age and maintain them as you mature. However, a recent report published in the
American Journal of Clinical Nutrition, suggests that adopting good nutritional choices later in life, during the forties, fifties, and
even the sixties, may still help to reduce the risk of chronic disease as you grow older.[8]
Even if past nutritional and lifestyle choices were not aligned with dietary guidelines, older adults can still do a great deal to reduce
their risk of disability and chronic disease. As we age, we tend to lose lean body mass. This loss of muscle and bone can have
critical health implications. For example, a decrease in body strength can result in an increased risk for fractures because older

15.4.3 [Link]
adults with weakened muscles are more likely to fall, and to sustain serious injuries when they do. However, improving your diet
while increasing physical activity helps to control weight, reduce fat mass, and maintain muscle and bone mass.
There are a number of changes middle-aged adults can implement, even after years of unhealthy choices. Choices include eating
more dark, green, leafy vegetables, substituting high-fat proteins with lean meats, poultry, fish, beans, and nuts, and engaging in
moderate physical activity for thirty minutes per day, several days per week. The resulting improvements in body composition will
go a long way toward providing greater protection against falls and fractures, and helping to ward off cardiovascular disease and
hypertension, among other chronic conditions.[9]

References
1. American Medical Association. (2008). Complete Guide to Prevention and Wellness. Hoboken, NJ: John Wiley & Sons, Inc.,
512. ↵
2. American Medical Association. (2008). Complete Guide to Prevention and Wellness. Hoboken, NJ: John Wiley & Sons,
Inc.,421. ↵
3. McMillan, B. (2008). Illustrated Atlas of the Human Body. Weldon Owen, 260. ↵
4. Deaths and Mortality. Centers for Disease Control, National Center for Health Statistics.
[Link] Updated May 3, 2017. Accessed December 9, 2017. ↵
5. Morley, JE. (1997). Anorexia of Aging: Physiologic and Pathologic. American Journal of Clinical Nutrition, 66, 760–73.
[Link]/content/66/4/[Link]. Accessed November 12, 2017. ↵
6. American Medical Association. (2008). Complete Guide to Prevention and Wellness. Hoboken, NJ: John Wiley & Sons, Inc.,
413. ↵
7. American Medical Association. (2008). Complete Guide to Prevention and Wellness. Hoboken, NJ: John Wiley & Sons, Inc.,
415. ↵
8. Rivlin, RS. (2007). Keeping the Young-Elderly Healthy: Is It Too Late to Improve Our Health through Nutrition?. American
Journal of Clinical Nutrition, 86, 1572S–6S. ↵
9. Rivlin, RS. (2007). Keeping the Young-Elderly Healthy: Is It Too Late to Improve Our Health through Nutrition?. American
Journal of Clinical Nutrition, 86, 1572S–6S. ↵

This page titled 15.4: Older Adulthood- The Golden Years is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated
by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal via source content that was edited to the style and standards of the
LibreTexts platform.
15.4: Older Adulthood- The Golden Years by Jennifer Draper, Marie Kainoa Fialkowski Revilla, & Alan Titchenal is licensed CC BY-NC-
SA 4.0. Original source: [Link]

15.4.4 [Link]
 CHAPTER OVERVIEW

16: Food Politics and Perspectives

In this chapter, food politics, sustainability, the food industry, food security, and diets from around the world are explored.
16.1: Prelude to Food Politics and Perspectives
16.2: Historical Perspectives on Food
16.3: The Food Industry
16.4: The Politics of Food
16.5: Food Cost and Inflation
16.6: The Issue of Food Security
16.7: Nutrition and Your Health
16.8: Diets around the World
16.E: Food Politics and Perspectives (Exercise)

Template:HideTOC
Thumbnail: Members of the Pure Milk Association dump milk before it could get to a non-member dairy in Harvard, Illinois
sometime in the 1930s. The successful “Milk Strike” led to organizing farmers to get higher prices for their milk. Image is
considered public domain.

16: Food Politics and Perspectives is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

1
16.1: Prelude to Food Politics and Perspectives
Big Ideas
Sustainability promotes nutrition today and protects natural resources for tomorrow.

As discussed in previous chapters, sustainability is a word that’s often talked about in the realm of food and nutrition. The term
relates to the goal of achieving a world that meets the needs of its present inhabitants while preserving resources for future
generations. As awareness about sustainability has increased among the media and the public, both agricultural producers and
consumers have made more of an effort to consider how the choices they make today will impact the planet tomorrow.

Figure : Raising free-range chickens that feed out in the open is

one example of a sustainable agricultural practice. Free Range Hens The eggs these hens produce will be pretty tasty. from Adam
Ward (via Wikipedia).
However, defining sustainability can be difficult because the term means different things to different groups. For most, sustainable
agriculture can best be described as an umbrella term that encompasses food production and consumption practices that do not
harm the environment, that do support agricultural communities, and that are healthy for the [Link] Table.
“Introduction to Sustainability.” Accessed October 10, 2011. [Link]/intro/. From factory farms to smaller-scale
ranches and granges, sustainable farming practices are being implemented more and more as the long-term viability of the current
production system has been called into question.
Yet, the concept of sustainability is not new to agricultural science, practice, or even policy. It has evolved throughout modern
history as a way to achieve self-reliance. It is also a vehicle for maintaining rural communities and supporting the concept of
conservation and protection of the [Link] Agriculture Projects. “A History of Sustainable Agriculture.” © 1990 Rod
MacRae. [Link] In 1990, the US federal government defined sustainable agriculture in a piece of
legislation known as the Farm Bill. The practice was described as an integrated system of plant and animal production that satisfies
human needs for food, along with fiber for fabric and other uses. The Farm Bill further defines sustainable agriculture as a practice
that enhances environmental quality and also the natural resource base upon which the agricultural economy depends. Sustainable
agriculture also makes the most efficient use of nonrenewable resources, sustains the economic viability of farm operations, and
supports the quality of life for farmers and society as a [Link], M.V. “Sustainable Agriculture: Definitions and Terms.” US
Department of Agriculture, National Agricultural Library. Special Reference Briefs Series no. SRB 99-02 (September 1999, August
2007). [Link]
In other words, the practice of sustainable agriculture strives to eschew conventional farming methods, including the cultivation of
single crops and row crops continuously over many seasons, the dependency on agribusiness, and the rearing of livestock in
concentrated, confined [Link], M.V. “Sustainable Agriculture: Definitions and Terms.” US Department of Agriculture,
National Agricultural Library. Special Reference Briefs Series no. SRB 99-02 (September 1999, August 2007).
[Link] Instead, sustainability includes a focus on biodiversity among both crops
and livestock; conservation and preservation to replenish the soil, air, and water; animal welfare; and fair treatment and wages for

16.1.1 [Link]
farm [Link] Table. “What Is Sustainable Agriculture?” Accessed October 10, 2011.
[Link]/intro/whatis/. Sustainable agriculture also encourages the health of consumers by rejecting extensive use
of pesticides and fertilizers and promoting the consumption of organic, locally produced food. Although many farmers and food
companies work to implement these practices, some use the idea of sustainability to attract consumers without completely
committing to the concept. “Greenwashing” is a derisive term (similar to “whitewashing”) for a corporation or industry falsely
utilizing a proenvironmental image or message to expand its market base.
Sustainability depends not only on agricultural producers, but also on consumers. The average person can do a number of things to
consume a more sustainable diet, from eating less meat to purchasing fruits and vegetables grown on nearby farms. For example,
produce sold in the Midwest typically travels an average of more than fifteen hundred miles from farm to supermarket. However,
increasing the consumption of more locally-grown produce by 10 percent would save thousands of gallons in fossil fuel each
[Link], M. C., G. A. Keoleian. “US Food System Factsheet.” Center for Sustainable Systems, University of Michigan. CSS
Factsheets, no. CSS01-06 (2001). [Link]

You Decide
How will you adapt your lifestyle and dietary choices to help promote sustainable agricultural practices?

Some consumers are choosing to make smarter nutritional choices, eat healthier foods, and enjoy fresh, locally grown products.
They read the labels on products in their local stores, make more home-cooked meals using whole-food ingredients, and pay
attention to the decisions that legislators and other officials make regarding food production and consumption. Will you be one of
them? How you can adjust your dietary selections to benefit not only your body and mind but also to help sustain the planet for
future generations?

Green Careers: Sustainable Agriculture …

Video : Green Careers: Sustainable Agriculture. This video focuses on

the role of a farm manager on a small farm that follows sustainable
agricultural practices.

16.1: Prelude to Food Politics and Perspectives is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

16.1.2 [Link]
16.2: Historical Perspectives on Food
Learning Objectives
Contrast ancient perspectives on food and nutrition with more modern explanatory systems

Throughout history, our relationship with food has been influenced by changing practices and perspectives. From the invention of
agriculture to the birth of refrigeration, technological advances have also affected what we eat and how we feel about our food.
Therefore, it can be helpful to examine theories and customs related to diet and nutrition across different civilizations and time
periods.

Civilizations and Time Periods

Diet and cuisine have undergone enormous changes from ancient times to today. The basic diet of the ancient era consisted of
cereals, legumes, oil, and wine. These staples were supplemented by vegetables and meat or fish, along with other items, such as
honey and salt. During the Middle Ages, poor people consumed meager diets that consisted of small game supplemented with
either barley, oat, or rye, while the wealthy had regular access to meat and fish, along with [Link] Food Recipes. “European
Medieval Food.” © 2011–2012. [Link]/[Link]. During the Industrial Revolution, diets became
more varied, partly because of the development of refrigeration and other forms of food preservation. In the contemporary era,
many people have access to a wide variety of food that is grown locally or shipped from far-off places.

Figure : Flatbread made from barley or wheat was a staple

in the traditional diet during the ancient era. Image used with permissin (CC -BY-SA 3.0; Jonathunder).

Hunters and Gatherers

Human beings lived as hunters and gatherers until the invention of agriculture. Following a nomadic lifestyle, early people hunted,
fished, and gathered fruit and wild berries, depending on their location and the availability of wild plants and wild game. To aid
their constant quest for food, humans developed weapons and tools, including spears, nets, traps, fishing tackle, and the bow and
[Link] Food Recipes. “Pre Historic Food.” © 2011–2012. [Link]/pre-...[Link].

The Beginning of Agriculture

About ten thousand years ago, people began to cultivate crops and domesticate livestock in Mesopotamia, an area of the world that
is known today as the Middle East. Agriculture flourished in this region due to the fertile floodplain between the Euphrates and
Tigris Rivers, and early crops included wheat, barley, and dates. The development of agriculture not only enriched the diet of these
early people, it also led to the birth of civilization as farmers began to settle into sizable, stable [Link]. “History of
Agriculture.” Accessed October 10, 2011. [Link]/agricultu...ry-agriculture.
One of the most fertile regions of the ancient world was located along the Nile River Valley in ancient Egypt. The rich soil yielded
several harvests per year. Common crops were barley, wheat, lentils, peas, and cabbage, along with grapes, which were used to

16.2.1 [Link]
make wine. Even poor Egyptians ate a reasonably healthy diet that included fish, vegetables, and fruit. However, meat was
primarily a privilege of the rich. Popular seasonings of this era included salt, pepper, cumin, coriander, sesame, fennel, and
[Link] Ancient Egypt. “Ancient Egyptian Food: The Pharaonic Diet.” © 2009–2011. [Link]
egypt....[Link].

The “Three Sisters”

Thousands of years ago, across an area that encompasses Mexico and Central America today,Foundation for the Advancement of
Mesoamerican Studies. “Mesoamerica.” Accessed October 10, 2011. [Link] Mesoamerican farmers cultivated three
major plants—squash, beans, and maize (also known as corn). Known as the “three sisters,” these crops proved to be both
complementary and sustainable. Corn provides a pole for bean vines to climb. The roots of bean vines provide nitrogen that helps
corn grow. These vines also stabilize corn stalks by making them less vulnerable to the wind. Shallow-rooted squash vines prevent
the evaporation of soil moisture, while their spiny plants discourage predators. Both of these attributes aid the cultivation of all
three [Link]’s Garden. “Celebrate the Three Sisters,” During the post-Columbian era, Native American groups adopted the
practice of interplanting squash, beans, and maize, and now thousands of years later, many small farmers continue to cultivate the
“three sisters.”

Meals Determined Social Status

In ancient Rome, differences in social standing affected the diet. For people of all socioeconomic classes, breakfast and lunch were
typically light meals that were often consumed in taverns and cafes. However, dinners were eaten at home and were taken much
more seriously. Wealthy senators and landowners ate meals with multiple courses, including appetizers, entrees, and desserts. Rich
Romans also held extravagant dinner parties, where guests dined on exotic foods, such as roasted ostrich or pheasant. In contrast,
people of the lower classes ate mostly bread and [Link]. “Home Life.” The Roman Empire in the First Century. © 2006
Devillier Donegan Enterprises. [Link] The average person ate out of clay dishes,
while wealthy people used bronze, gold, or silver.
Social status determined the kinds of food that people consumed in many other parts of the world as well. In ancient China,
emperors used their wealth and power to hire the best chefs and acquire delicacies, such as honey, to sweeten food. Dishes of the
ancient era included steamed Mandarin fish, rice and wheat noodles, and fried prawns. Imperial cuisine also included improved
versions of dishes that were consumed by the common people, such as soups and [Link]. “The History of Chinese
Imperial Cuisines.” © China Information Center. Accessed December 5, 2011.
[Link]

The Medieval Era

The eating habits of most people during the Medieval Era depended mainly on location and financial status. In the feudal system of
Europe, the majority of the population could not afford to flavor their food with extravagant spices or sugar. In addition,
transporting food was either outrageously expensive or out of the question due to the inability to preserve food for a long period of
time. As a result, the common diet consisted of either wheat, meat, or fish, depending on location. The typical diet of the lower
classes was based on cereals and grains, porridge, and gruel. These staples were supplemented with seasonal fruits, vegetables, and
herbs. Wine, beer, and cider were also common, and were often safer to drink than the unsanitized, untreated water.

The Crusades
During the Medieval Era, soldiers from Europe waged war over religion in the Middle East in military campaigns that came to be
known as the Crusades. Upon their return, the crusaders brought back new foods and spices, exposing Europeans of the Middle
Ages to unusual flavors. Cooking with exotic spices, such as black pepper, saffron, and ginger, became associated with wealth
because they were expensive and had to be imported.

Food Preservation in the Past

During the Medieval and Renaissance eras, most meals consisted of locally grown crops because it was extremely difficult to
transport food over long distances. This was mostly due to an inability to preserve food for long periods. At that time, food

16.2.2 [Link]
preservation consisted mostly of drying, salting, and smoking. Pickling, which is also known as brining or corning, was another
common practice and involved the use of fermentation to preserve food.

The Modern Era

The modern era began in North America and Europe with the dawn of the Industrial Age. Before that period, people predominantly
lived in agrarian communities. Farming played an important role in the development of the United States and Canada. Almost all
areas of the country had agrarian economies dictated by the harvesting seasons.
In the 1800s, society began to change as new machines made it easier to cultivate crops, and to package, ship, and store food. The
invention of the seed drill, the steel plow, and the reaper helped to speed up planting and harvesting. Also, food could be
transported more economically as a result of developments in rail and refrigeration. These and other changes ushered in the modern
era and affected the production and consumption of food.

Food Preservation in Modern Times

Technological innovations during the 1800s and 1900s also changed the way we cultivate, prepare, and think about food. The
invention and refinement of the refrigerator and freezer made it possible for people to store food for much longer periods. This, in
turn, allowed for the transportation of food over greater distances. For example, oranges grown in Florida would still be fresh when
they arrived in Seattle.
Prior to refrigeration, people relied on a number of different methods to store and preserve food, such as pickling. Other
preservation techniques included using sugar or honey, canning, and preparing a confit, which is one of the oldest ways to preserve
food and involves salting meat and cooking it in its own fat. To store foods for long periods, people used iceboxes or kept
vegetables, such as potatoes, onions, and winter squash, in cellars during the winter months.

The Great Depression

During the Great Depression of the 1930s, the United States faced incredible food shortages and many people went hungry. This
was partly because extreme droughts turned parts of the Midwest into a Dust Bowl, where farmers struggled to raise crops.
Millions of Americans were unemployed or underemployed and were forced to wait in long breadlines for free food. This was also
a period of incredible reforms, as the government worked to provide for and protect the people. Some important changes included
subsidies and support for suffering farmers.

World War II
Food shortages also occurred during World War II in the 1940s. At that time, people voluntarily made due with less to ensure that
soldiers training and fighting overseas had the supplies they needed. To focus on saving at home, government programs included
rationing food (particularly meat, butter, and sugar), while the media encouraged families to plant their own fruits and vegetables in
“victory” (backyard) gardens.

Contemporary Life
Today, agriculture remains a large part of the economy in many developing nations. In fact, nearly 50 percent of the world’s labor is
employed in [Link]. “History of Agriculture.” Accessed October 10, 2011. [Link]/agricultu...ry-
agriculture. In the United States however, less than 2 percent of Americans produce food for the rest of the [Link], M.V.
“Sustainable Agriculture: Definitions and Terms.” US Department of Agriculture, National Agricultural Library. Special Reference
Briefs Series no. SRB 99-02 (September 1999, August 2007). [Link] Also, most
farms are no longer small-scale or family-owned. Large-scale agribusiness is typical for both crop cultivation and livestock rearing,
including concentrated animal feeding operations. Conventional farming practices can include abuses to animals and the land.
Therefore, more and more consumers have begun to seek out organic and locally grown foods from smaller-scale farms that are
less harmful to the environment.
Other changes also affect food production and consumption in the modern era. The invention of the microwave in the 1950s
spurred the growth of frozen foods and TV dinners. Appliances such as blenders and food processors, toasters, coffee and espresso

16.2.3 [Link]
machines, deep fryers, and indoor grills have all contributed to the convenience of food preparation and the kinds of meals that
people enjoy cooking and eating.

Diet Trends Over Time

Today, consumers can choose from a huge variety of dietary choices that were not available in the past. For example, strawberries
can be purchased in New York City in wintertime, because they are quickly and easily transported from places where the crop is in
season, such as California, Mexico, or South America. In the western world, especially in North America, food products are also
relatively cheap. As a result, there is much less disparity between the diets of the lower and upper classes than in the past. It would
not be unusual to find the same kind of meat or poultry served for dinner in a wealthy neighborhood as in a poorer community.

Key Takeaways
Perspectives and practices related to food and nutrition have greatly changed from the ancient era to today. In the ancient world,
location and economic status had a profound effect on what people ate. Also, societies often were based on crop cultivation and
livestock rearing, which influenced how people ate, worked, and lived. During the Medieval Era, people became more exposed to
food from other parts of the world because of the growing ability to ship goods and because of the Crusades, among other factors.
Technological advances, such as refrigeration and the microwave, have had huge effects on the way food is produced and
consumed.

Discussion Starter
1. Compare and contrast the diet of a civilization from the ancient world or the Medieval Era to the food choices of today. In what
ways has our diet changed? In what ways has it remained the same?

16.2: Historical Perspectives on Food is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

16.2.4 [Link]
16.3: The Food Industry
Learning Objectives
Explain what is meant by the term “the food industry” and identify the food technologies and innovations that have shaped
the current food system

Agriculture is one of the world’s largest industries. It encompasses trillions of dollars and employs billions of people. In the United
States alone, customers spent about $500 billion annually on food products at grocery stores and [Link] Research,
Ltd. “US Food Industry Overview.” Accessed December 5, 2011, [Link]
%20research/industry%20statistics. The food industry includes a complex collective of businesses that touches on everything from
crop cultivation to manufacturing and processing, from marketing and advertising to distribution and shipment, to food regulation.

The Food System

The food system is a network of farmers and related operations, including food processing, wholesale and distribution, retail,
industry technology, and marketing. The milk industry, for example, includes everything from the farm that raises livestock, to the
milking facility that extracts the product, to the processing company that pasteurizes milk and packages it into cartons, to the
shipping company that delivers the product to stores, to the markets and groceries that stock and sell the product, to the advertising
agency that touts the product to consumers. All of these components play a part in a very large system.

Figure : These cows are lined up at a Rotary milking

parlor. (CC BY-SA 3.0; Gunnar Richter [Link]).

Food Preservation and Processing

Two important aspects of a food system are preservation and processing. Each provides for or protects consumers in different ways.
Food preservation includes the handling or treating of food to prevent or slow down spoilage. Food processing involves
transforming raw ingredients into packaged food, from fresh-baked goods to frozen dinners. Although there are numerous benefits
to both, preservation and processing also pose some concerns, in terms of both nutrition and sustainability.

Food Preservation
Food preservation protects consumers from harmful or toxic food. There are different ways to preserve food. Some are ancient
methods that have been practiced for generations, such as curing, smoking, pickling, salting, fermenting, canning, and preserving
fruit in the form of jam. Others include the use of modern techinques and technology, including drying, vacuum packing,
pasteurization, and freezing and refrigeration. Preservation guards against food-bourne illnesses, and also protects the flavor, color,
moisture content, or nutritive value of food.

16.3.1 [Link]
Irradiation
Another method of preservation is irradiation, which reduces potential pathogens to enhance food safety. This process involves
treating food with ionizing radiation, which kills the bacteria and parasites that cause toxicity and disease. Similar technology is
used to sterilize surgical instruments to avoid [Link] for Disease Control and Prevention. “Food Irradiation.” Accessed
October 11, 2005. [Link]/ncidod/dbmd/disea...[Link]. Foods currently approved for irradiation by the FDA include
flour, fruits and vegetables, juices, herbs, spices, eggs, and meat and poultry.
Most forms of preservation can affect the quality of food. For example, freezing slightly affects the nutritional content, curing and
smoking can introduce carcinogens, and salting greatly increases the sodium. There are also concerns about the effects of using
irradiation to preserve food. Studies have shown that this process can change the flavor, texture, color, odor, and nutritional content
of food. For example, the yolks of irradiated eggs have less color than nonirradiated eggs.

Food Processing
Food processing includes the methods and techniques used to transform raw ingredients into packaged food. Workers in this
industry use harvested crops or slaughtered and butchered livestock to create products that are marketed to the public. There are
different ways in which food can be processed, from a one-off product, such as a wedding cake, to a mass-produced product, such
as a line of cupcakes packaged and sold in stores.

The Pros and Cons of Food Processing

Food processing has a number of important benefits, such as creating products that have a much longer shelf life than raw foods.
Also, food processing protects the health of the consumer and allows for easier shipment and the marketing of foods by
corporations. However, there are certain drawbacks. Food processing can reduce the nutritional content of raw ingredients. For
example, canning involves the use of heat, which destroys the vitamin C in canned fruit. Also, certain food additives that are
included during processing, such as high fructose corn syrup, can affect the health of a consumer. However, the level of added
sugar can make a major difference. Small amounts of added sugar and other sweeteners, about 6 to 9 teaspoons a day or less, are
not considered [Link] Heart Association. “Sugar and Carbohydrates.” Last updated October 12, 2010.
[Link]/HEARTORG/Gettin...6_Article.jsp#.

Figure : Industrial cheese production. 10,000 l milk in the left tank, the
milk was mixed with rennet and is now broken for the production of Emmentaler.. (CC BY-SA 3.0; MatthiasKabel).

Food Regulation and Control

Food regulatory agencies work to protect the consumer and ensure the safety of our food. Food and drug regulation in the United
States began in the late nineteenth century when state and local governments began to enact regulatory policies. In 1906, Congress
passed the Pure Food and Drugs Act, which led to the creation of the US Food and Drug Administration (FDA). Today, a number of
agencies are in charge of monitoring how food is produced, processed, and [Link] Encyclopedia. “History of Food and
Drug Regulation in the United States.” February 4, 2010. [Link]/encyclopedia/article/L...[Link].

Regulatory Agencies
Food regulation is divided among different agencies, primarily the FDA and the US Department of Agriculture (USDA).
Regulatory agencies in Canada include the Canadian Food Inspection Agency and Health Canada. The North American public

16.3.2 [Link]
depends on these and other agencies to ensure that the food they purchase and consume from supermarkets, restaurants, and other
sources is safe and healthy to eat. It can be confusing to know which agency monitors and manages which regulatory practice. For
example, the FDA oversees the safety of eggs when they’re in the shells, while the USDA is in charge of the eggs once they are out
of their shells.

The Food and Drug Administration

The FDA enforces the safety of domestic and imported foods. It also monitors supplements, food labels, claims that corporations
make about the benefits of products, and pharmaceutical drugs. Sometimes, the FDA must recall contaminated foods and remove
them from the market to protect public health. For example, in 2011 contaminated peanut butter led to the recall of thousands of
jars of a few popular [Link] Food and Drug Administration. “FDA 101: Product Recalls—From First Alert to Effectiveness
Checks.” Last updated September 9, 2011. [Link] Recalls are almost always
voluntary and often are requested by companies after a problem has been discovered. In rare cases, the FDA will request a recall.
But no matter what triggers the removal of a product, the FDA’s role is to oversee the strategy and assess the adequacy and
effectiveness of the recall.

Video : FDA 101: Product Recalls. This video explains how the FDA
recalls contaminated products to protect consumers.

The US Department of Agriculture

Headed by the Secretary of Agriculture, the USDA develops and executes federal policy on farming and food. This agency supports
farmers and ranchers, protects natural resources, promotes trade, and seeks to end hunger in the United States and abroad. The
USDA also assures food safety, and in particular oversees the regulation of meat, poultry, and processed egg products.

The Environmental Protection Agency

A third federal government agency, the Environmental Protection Agency (EPA), also plays a role in the regulation of food. The
EPA works to protect human health and the environment. Founded in 1970, the agency conducts environmental assessment,
education, research, and regulation. The EPA also works to prevent pollution and protect natural resources. Two of its many
regulatory practices in the area of agriculture include overseeing water quality and the use of pesticides.

Food Safety and Hazard Analysis

Government regulatory agencies utilize HACCP programs to ensure food safety. HACCP, or hazard analysis and critical control
points, is a system used to identify potential hazards and prevent foodbourne illnesses. Some of the seven aspects of an HACCP
program include identifying the points in a manufacturing process during which potential hazards could be introduced, establishing
corrective actions, and maintaining record-keeping procedures. The USDA uses HACCP to regulate meat, while the FDA uses the
seven-point system to monitor seafood and juice. In these industries, HACCP systems are used in all stages of production,
processing, packaging, and [Link] Food and Drug Administration. “Hazard Analysis & Critical Control Points (HACCP).”
Last updated April 27, 2011. [Link]/food/foodsafety/h...cp/[Link]. Currently, the use of HACCP is voluntary for all
other food products.

16.3.3 [Link]
Food Additives
If you examine the label for a processed food product, it is not unusual to see a long list of added materials. These natural or
synthetic substances are food additives and there are more than three hundred used during food processing today. The most popular
additives are benzoates, nitrites, sulfites, and sorbates, which prevent molds and yeast from growing on [Link] Stuff Works.
“The Dangers of Food Additives.” Accessed October 5, 2011. [Link]
nutrition/facts/dangers-of-food -[Link].
Food additives are introduced in the processing stage for a variety of reasons. Some control acidity and alkalinity, while others
enhance the color or flavor of food. Some additives stabilize food and keep it from breaking down, while others add body or
texture. Table lists some common food additives and their uses:
Table : Food Additives
Additive Reason for Adding

Beta-carotene Adds artificial coloring to food

Caffeine Acts as a stimulant

Citric acid Increases tartness to prevent food from becoming rancid

Dextrin Thickens gravies, sauces, and baking mixes

Gelatin Stabilizes, thickens, or texturizes food

Modified food starch Keeps ingredients from separating and prevents lumps

MSG Enhances flavor in a variety of foods

Pectin Gives candies and jams a gel-like texture

Polysorbates Blends oil and water and keep them from separating

Soy lecithin Emulsifies and stabilizes chocolate, margarine, and other items

Sulfites Prevent discoloration in dried fruits

Xanthan gum Thickens, emulsifies, and stabilizes dairy products and dressings

Source: Center for Science in the Public Interest. “Chemical Cuisine: Learn about Food Additives.” ©2012. Center for Science in
the Public Interest. [Link]

The Pros and Cons of Food Additives

The FDA works to protect the public from potentially dangerous additives. Passed in 1958, the Food Additives Amendment states
that a manufacturer is responsible for demonstrating the safety of an additive before it can be approved. The Delaney Clause that
was added to this legislation prohibits the approval of any additive found to cause cancer in animals or humans. However, most
additives are considered to be “generally recognized as safe,” a status that is determined by the FDA and referred to as GRAS.
Food additives are typically included in the processing stage to improve the quality and consistency of a product. Many additives
also make items more “shelf stable,” meaning they will last a lot longer on store shelves and can generate more profit for store
owners. Additives can also help to prevent spoilage that results from changes in temperature, damage during distribution, and other
adverse conditions. In addition, food additives can protect consumers from exposure to rancid products and food-bourne illnesses.
Food additives aren’t always beneficial, however. Some substances have been associated with certain diseases if consumed in large
amounts. For example, the FDA estimates that sulfites can cause allergic reactions in 1 percent of the general population and in 5
percent of asthmatics. Similarly, the additive monosodium glutamate, which is commonly known as MSG, may cause headaches,
nausea, weakness, difficulty breathing, rapid heartbeat, and chest pain in some [Link] Table. “The Issues:
Additives.” Accessed October 10, 2011. [Link]/issu...dditives/#fn14.

16.3.4 [Link]
The Effect of New Technologies
As mentioned earlier, new technology has had a tremendous effect on the food we eat and the customs and culture related to food
consumption. For example, microwaves are used to reduce cooking time or to heat up leftover food. Refrigerators and freezers
allow produce to travel great distances and last longer. On the extreme end of making food last longer, there is special food for
astronauts that is appropriate for consumption in space. It is safe to store, easy to prepare in the low-gravity environment of a
spacecraft, and contains balanced nutrition to promote the health of people working in space. In the military, soldiers consume
Meals Ready-to-Eat (MREs), which contain an entire meal in a single pouch.

Genetically Modified Foods

Genetically modified foods (also known as GM or GMO foods), are plants or animals that have undergone some form of genetic
engineering. In the United States, much of the soybean, corn, and canola crop is genetically modified. The process involves the
alteration of an organism’s DNA, which allows farmers to cultivate plants with desirable [Link].
“What Are Genetically Modified Foods?” Last modified November 5, 2008. [Link]
For example, scientists could extract a gene that produces a chemical with antifreeze properties from a fish that lives in an arctic
region (such as a flounder). They could then splice that gene into a completely different species, such as a tomato, to make it
resistant to frost, which would enable farms to grow that crop [Link], D. B. “Genetically Modified Foods: Harmful
or Helpful?” ProQuest Discovery Guides (April 2000). [Link]/discoveryguides/g...d/[Link].
Certain modifications can be beneficial in resisting pests or pesticides, improving the ripening process, increasing the nutritional
content of food, or providing resistance to common viruses. Although genetic engineering has improved productivity for farmers, it
has also stirred up debate about consumer safety and environmental protection. Possible side effects related to the consumption of
GM foods include an increase in allergenicity, or tendencies to provoke allergic reactions. There is also some concern related to the
possible transfer of the genes used to create genetically engineered foods from plants to people. This could influence human health
if antibiotic-resistant genes are transferred to the consumer. Therefore, the World Health Organization (WHO) and other groups
have encouraged the use of genetic engineering without antibiotic-resistance genes. Genetically modified plants may adversely
affect the environment as well and could lead to the contamination of nongenetically engineered [Link] Health
Organization. “Food Safety: 20 Questions on Genetically Modified Foods.” © 2011.
[Link]
Genetically modified foods fall under the purview of the EPA, the USDA, and the FDA. Each agency has different responsibilities
and concerns in the regulation of GM crops. The EPA ensures that pesticides used for GM plants are safe for the environment. The
USDA makes sure genetically engineered seeds are safe for cultivation prior to planting. The FDA determines if foods made from
GM plants are safe to eat. Although these agencies act independently, they work closely together and many products are reviewed
by all [Link], D. B. “Genetically Modified Foods: Harmful or Helpful?” ProQuest Discovery Guides (April 2000).

Too Much Controversy over Genetically …

Video : Too Much Controversy Over Genetically Modified Foods?

16.3.5 [Link]
Food Enrichment and Fortification
Many foods are enriched or fortified to boost their nutritional value. Enrichment involves adding nutrients to restore those that were
lost during processing. For example, iron and certain B vitamins are added to white flour to replace the nutrients that are removed
in the process of milling wheat. Fortification is slightly different than enrichment and involves adding new nutrients to enhance a
food’s nutritive value. For example, folic acid is typically added to cereals and grain products, while calcium is added to some
orange juice.

The Health of the Population

Certain enrichment and fortification processes have been instrumental in protecting public health. For example, adding iodine to
salt has virtually eliminated iodine deficiencies, which protects against thyroid problems. Adding folic acid to wheat helps increase
intake for pregnant women, which decreases the risk of neural tube defects in their children. Also, vegans or other people who do
not consume many dairy products are able to drink orange juice or soy milk that has been fortified with calcium to meet the daily
recommendations. However, there is some concern that foods of little nutritive value will be fortified in an effort to improve their
allure, such as soft drinks with added vitamins.

Key Takeaways
The food industry encompasses all aspects of food production: manufacturing, distribution, marketing, retail, regulation, and
consumption. Food preservation and processing have a number of benefits including improving the quality of food products,
making them more shelf-stable, and aiding the marketing and advertising of food. There are more than three hundred additives used
during food processing today. Food preservation and processing also have some drawbacks, including potentially damaging the
nutritive value of food. The cultivation and consumption of genetically modified foods are also highly controversial, with many
people opposed to the genetic modification of crops. There are three key government agencies that regulate food in the United
States: the US Department of Agriculture, the US Food and Drug Administration, and the US Environmental Protection Agency.

Discussion Starter
1. Discuss the debate about the use of food additives, such as beta-carotene and citric acid. What are the benefits to using them?
What are the drawbacks? Do you believe that food additives are more helpful or more harmful, and why?

16.3: The Food Industry is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

16.3.6 [Link]
16.4: The Politics of Food
Learning Objectives
Discuss how food has become politicized, and give specific examples of how food choices are related to food politics

Some people have begun to view their choices regarding diet and nutrition in light of their political views. More and more,
consumers weigh their thoughts on the environment and the world, while making decisions about what to purchase in the grocery
store. For example, many people choose to eat free-range chickens due to concerns about animal welfare. Others worry about the
higher cost of organically produced food or find that those products are not available in their communities. As a result, feelings
about food have become a political mine field.

Food Politics
The production and sale of food is an extremely big business and touches people in all industries and walks of life. Food is not only
crucial for day-to-day survival, but also strongly affects overall health and well-being, as well as the economy and culture of a
region or a country. So, it is no wonder that more and more producers and consumers alike are speaking out about food to ensure
that their interests are protected. Food politics can influence many stakeholders and interests, but always involve the production,
regulation, inspection, distribution, and/or retail of food.

Stakeholders
Stakeholders in food politics include large and small farmers, along with large and small food companies. Other important
stakeholders include restaurants and other food-service providers, food distributors, grocery stores and other retail outlets,
consumers, and trade associations. Antihunger advocates, nutrition advocates, and food-industry lobbyists also have important roles
to play. Nongovernmental organizations, such as the American Cancer Society and the WHO, also work to promote good health
and nutrition. Each group has its own perspective and its own agenda in disputes related to food.

Disputes
Food politics can be influenced by ethical, cultural, medical, and environmental disputes over agricultural methods and regulatory
policies. They are also greatly influenced by manufacturing processes, marketing practices, and the pursuit of the highest possible
profit margin by food manufacturers and distributers. Common disputes and controversies include the genetic modification of
plants, the potential dangers of food additives, chemical run-off from large-scale farms, and the reliance on factory-farming
practices, such as the use of pesticides in crop cultivation and antibiotics in livestock feed. Additional issues and concerns include
the use of sugar, salt, and other potentially unhealthy ingredients, the promotion of fast food and junk food to children, and sanitary
standards related to livestock.

The Nitrate Dispute

One current dispute relates to the use of nitrates in agriculture. At the dawn of the twentieth century, German chemists Fritz Haber
and Carl Bosch invented a system that synthesizes ammonia to produce nitrates on an industrial scale. The compound could then be
used to make fertilizers, which along with pesticides and herbicides, made large-scale, modern agriculture possible. However, when
nitrates are used in excess, they can create runoff that pollutes surface- and groundwater. For example, chemical runoff has had a
profound effect on the Aral Sea and the surrounding area in Kazakhstan and Uzbekistan. The Aral Sea, which was once one of the
four largest lakes in the world, was crucial to irrigation projects in the former Soviet Union. But when the lake became
contaminated by farm runoff, salinity increased and the lake dramatically shrank, crippling the area’s fishing industry. Also, as the
lakebed became exposed, dust storms spread contaminated soil, and thousands of people were forced out of the [Link], L.
“Nitrates: Dangerous Necessity.” Environmentalism @ Suite [Link]. May 7, 2011. [Link]/nitr...essity-a369949.
Contaminated runoff from the use of nitrates not only leads to serious consequences for the environment, but also to human health.
Nitrate poisoning reduces the oxygen-carrying capacity of the blood and can be fatal to [Link] Environmental Protection
Agency. “Ag 101: Nitrate.” Last updated September 10, 2009. [Link] Therefore,
significant efforts are being made to use nitrates and other agricultural chemicals in more environmentally friendly ways and to
monitor drinking water for dangerous levels of contamination.

16.4.1 [Link]
The Role of Government
Federal and state policy plays a major role in the politics of food production and distribution. As previously discussed, government
agencies regulate the proper processing and preparation of foods, as well as overseeing shipping and storage. They pay particular
attention to concerns related to public health. As a result, the enforcement of regulations has been strongly influenced by public
concern over food-related events, such as outbreaks of food-bourne illnesses.

Food Production, Distribution, and Safety

Many consumers have concerns about safety practices during the production and distribution of food. This is especially critical
given recent outbreaks of food-borne illnesses. For example, during fall 2011 in the United States, there was an eruption of the
bacteria Listeria monocytogenes in cantaloupe. It was one of the deadliest outbreaks in over a decade and resulted in a number of
deaths and [Link] for Disease Control and Prevention. “Multistate Outbreak of Listeriosis Associated with Jensen
Farms Cantaloupe—United States.” August–September, 2011. [Link]
s_cid= mm6039a5_w.

Figure : Whole chickens are suspended in a public market. (CC-BY-SA; 3.0; Tomás
Castelazo)
In January 2011, the Food Safety Modernization Act was passed to grant more authority to the FDA to improve food safety. The
FDA and other agencies also address consumer-related concerns about protecting the nation’s food supply in the event of a terrorist
attack.

Addressing Hunger
Government agencies also play an important role in addressing hunger via federal food-assistance programs. The agencies provide
debit cards (formerly distributed in the form of food vouchers or food stamps) to consumers to help them purchase food and they
also provide other forms of aid to low-income adults and families who face hunger and nutritional deficits. This topic will be
discussed in greater detail later in this chapter.

The Dual Role of the USDA

The USDA has a dual role in the advancement of American agribusiness and the promotion of health and nutrition among the
public. This can create conflicts of interest, and some question whether the USDA values the interests of the agriculture and food
industries over consumer health.
However, there is no question that the USDA makes a great deal of effort to educate the public about diet and nutrition. Working
with the US Department of Health and Human Services, the agency codeveloped the Dietary Guidelines for Americans to inform
consumers about the ways their dietary habits affect their health. The USDA also implements all federal nutrition programs.

The Farm Bill

The Farm Bill (introduced in 1990) is a massive piece of legislation that determines the farm and food policy of the federal
government. It addresses policy related to federal food programs and other responsibilities of the USDA. The Farm Bill also covers
a wide range of agricultural programs and provisions, including farm subsidies and rural development. And, it influences
international trade, commodity prices, environmental preservation, and food safety.

16.4.2 [Link]
The massive Farm Bill is updated and renewed every five years. Over the decades, it has expanded to incorporate new issues, such
as conservation and bioenergy. The Farm Bill passed in 2008, known as the Food, Conservation, and Energy Act, included new
policy on horticulture and livestock provisions. The 2008 bill also differed from previous legislation in terms of the large number
and scope of proposals that were [Link], R. and J. Monke, “What Is the ‘Farm Bill’?” Congressional Research Service.
CRS Report for Congress, no. RS22131 (January 3, 2011). [Link]/a...rs/[Link].

Tools for Change

Start paying attention to the news when you hear about the next upcoming Farm Bill to learn about proposals that could affect the
food that arrives in your local supermarket or that is served in your favorite restaurant. To learn more about the upcoming
legislation, visit [Link] You may also wish to “vote with your fork” and make choices about what you eat
based on practices you approve of, such as choosing a vegetarian, vegan, organic, locavore, sustainable, slow-food movement or
other type of diet.

Agricultural Subsidies
The Farm Bill can directly and indirectly have wide-ranging effects. For example, the bill dictates subsidies and other forms of
agricultural funding or support. Farmers rely on this kind of support to offset varying crop yields and unfavorable weather
conditions. The agricultural industry also depends on the federal government to provide some form of price control to guard against
flooding the market and dragging down prices. As an example, major changes in the policy of agricultural subsidies were
implemented in the 1970s to increase farm incomes and produce cheaper food. As a result of these policies and subsidies, much
more corn was grown, giving rise to high fructose corn syrup as a primary sweetener in a number of products today, since corn
syrup is cheaper to produce. It is also sweeter than cane sugar, which encouraged its widespread use.
Historically, Congress has pursued farm support programs to ensure that the US population has continued access to abundant and
affordable food. However, some leaders worry about the effectiveness of government programs as well as the cost to taxpayers and
consumers. Others question if continued farm support is even needed and wonder if it remains compatible with current economic
objectives, domestic policy, trade policy, and regulatory [Link], R. and J. Monke, “What Is the ‘Farm Bill’?”
Congressional Research Service. CRS Report for Congress, no. RS22131 (January 3, 2011).
[Link]/a...rs/[Link]. For example, federal dairy policies can raise the price of milk and other dairy
products, which can detrimentally affect school lunch and food stamp programs. Regarding all of these issues, Congress must heed
the demands of its constituents. In the end, it is inevitable that consumers’ growing interest in food issues will affect not only the
choices they make in the grocery store, but also the decisions they make in the voting booth.

Key Takeaways
Food politics reflect changing perspectives and policies in the areas of production, distribution, marketing, regulation, and
consumption. Over the years, there have been a number of controversies and disputes over food, including concerns about additives
and GM foods, the push for sustainable agriculture, and the need to alleviate hunger. In the United States, a massive piece of
legislation known as the Farm Bill determines the agricultural and food policy of the federal government.

Discussion Starter
1. Debate a controversial issue related to food politics, such as sustainable agriculture, farm subsidies, or the Farm Bill. Identify
the stakeholders involved with the issue and discuss the pros and cons of the differing sides.

16.4: The Politics of Food is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

16.4.3 [Link]
16.5: Food Cost and Inflation
Learning Objectives
Cite a recent event that has had a profound effect on how consumers feel about the food supply.
Give a historical overview of the era of cheap food.

Statistics show that Americans spend more than $1.5 trillion on food each year at supermarkets, in restaurants, and from other food
[Link] Research, Ltd. “US Food Industry Overview.” 2011. [Link]
%20research/industry%20statistics. According to the USDA, a thrifty family of four spends about $540-$620 per month on
[Link] Department of Agriculture. “Official USDA Food Plans: Cost of Food at Home at Four Levels, US Average, August
2011.” Issued September 2011. [Link]/Publication...[Link]. A number of factors affect the rising cost of
food. They include agricultural production, processing and manufacturing, wholesale distribution, retail distribution, and
consumption.
Around the world, commodity prices rose sharply in 2010 as crop production shortfalls led to reduced supplies and a higher
volatility in agricultural markets. Other factors that played a role in increasing food prices include a population boom that has
drastically increased demand, droughts and other natural disasters that have crippled farmers, and trade policies and practices that
are unfair to developing nations.
Rising agricultural commodity prices have led to concerns about food insecurity and hunger. In an agricultural outlook report for
2010–2020, the Secretary-General of the Organisation for Economic Co-operation and Development states, “While higher prices
are generally good news for farmers, the effect on the poor in developing countries who spend a high proportion of their income on
food can be devastating. That is why we are calling on governments to improve information and transparency of both physical and
financial markets, encourage investments that increase productivity in developing countries, remove production and trade distorting
policies, and assist the vulnerable to better manage risk and uncertainty.”Organisation for Economic Co-operation and
Development. “OECD-FAO Agricultural Outlook 2010–2020.” June 17, 2011. [Link]/document/31/0,37..._1_1_1,[Link].

Who Bears the Cost?

The cost of our food is influenced by the policies and practices of farms, food and beverage companies, food wholesalers, food
retailers, and food service companies. These costs include the energy required to produce and distribute food products from farm
field to supermarket to table. Rising prices also reflect the marketing and advertising of food. All of these factors affect all
participants in a food system, but some participants are more affected than others. A 2011 report by the Economic Research Service
of the USDA shows the division of the consumer food dollar among various aspects of the American food system. A far greater
amount of the money you spend to buy a product goes toward the marketing components than toward the actual [Link]
Department of Agriculture, Economic Research Service. “Overview.” Last updated November 19, 2012.
[Link]

The Consumer Price Index

The Consumer Price Index (CPI) measures changes in the price level paid for goods and services. This economic indicator is based
on the expenditures of the residents of urban areas, including working professionals, the self-employed, the poor, the unemployed,
and retired workers, as well as urban wage earners and clerical workers. The CPI has subindices for many different types of
products, including food and beverages. It is a closely-watched statistic that is used in a variety of ways, including measuring
inflation and regulating prices.

Implications Around the World

Food prices and inflation disproportionately affect people at lower income levels. For the poorest people of the world, increasing
prices can raise levels of hunger and starvation. In many developing countries where the cost for staple crops steadily rises,
consumers have faced shortages or even the fear of shortages, which can result in hoarding and rioting. This happened in 2007 and
2008 during rice shortages in India and other parts of Asia. Rioters burned hundreds of food ration stores in the Indian region West
Bengal. In the West African nation Burkina Faso, food rioters looted stores and burned government buildings as a result of rising

16.5.1 [Link]
prices for food and other [Link] Walt, “The World’s Growing Food-Price Crisis,” Time Magazine, 27 February 2008.
[Link]/time/world/artic...7572-1,[Link]. In some poor countries, protests also have been fueled by concerns over
corruption, because officials earned fortunes from oil and minerals, while locals struggled to put food on their tables. Bringing
down prices would quell protests, but could take a decade or more to accomplish.

The End of the Era of Cheap Food

Concerns about food shortages and rising prices reflect the end of the era of cheap food. Following World War II, grain prices fell
steadily around the world for decades. As farms grew in scale, factory-farm practices, such as the use of synthetic and mined
fertilizers and pesticides, increased. Agribusinesses also invested in massive planting and harvesting machines. These practices
pushed crop yields up and crop prices down. Food became so inexpensive that we entered what came to be called the “era of cheap
food.”
However, by 2008, economic experts had declared that the era of cheap food was over. The rapid growth in farm output had slowed
to the point that it failed to keep pace with population increases and rising affluence in once-developing nations. Consumption of
four staples—wheat, rice, corn, and soybeans—outstripped production and resulted in dramatic stockpile decreases. The
consequence of this imbalance has been huge spikes felt moderately in the West and to a much greater degree in the developing
world. As a result, hunger has worsened for tens of millions of poor people around the [Link] Gillis, “A Warming Planet
Struggles to Feed Itself,” The New York Times, 4 June 2011. [Link]
Two major trends played a part in this shift. First, prosperity in India and China led to increased food consumption in general, but
more specifically to increased meat consumption. Increased meat consumption has led to an increased demand for livestock feed,
which has contributed to an overall rise in prices. The second trend relates to biofuels, which are made from a wide variety of crops
(such as corn and palm nuts), which increasingly are used to make fuel instead of to feed people.
The world population in 2010 was 6.9 [Link] Nations. “World Population Prospects, the 2010 Revision.”
[Link] It is projected to grow to 9.4 billion by [Link] and Agricultural
Organization of the United Nations. “Executive Summary.” [Link]/docrep/004/y3557e/[Link]. The rate of increase is
particularly high in the developing world, and the increased population, along with poverty and political instability, are helping to
foster long-term food insecurity. In the coming decades, farmers will need to greatly increase their output to meet the rising
demand, while adapting to any future [Link] Science Monitor. “Why the Era of Cheap Food Is Over.” December 31,
2007. [Link]

Key Takeaways
Food prices are rising in the United States and around the world, which has greatly affected both agricultural producers and
consumers. A number of factors have contributed to rising costs, including population booms, natural disasters, and the production
of biofuels, among others. Economic experts have declared that the era of cheap food, which began after World War II, has ended
due to rising population rates and decreased agricultural production worldwide. As a result, hunger has worsened for tens of
millions of poor people globally.

Discussion Starter
1. Examine the graphics from [Link] What does each image indicate about
agriculture and the American economy?

16.5: Food Cost and Inflation is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

16.5.2 [Link]
16.6: The Issue of Food Security
Learning Objectives
Share an example of a food and nutrition program that seeks to mitigate hunger in the United States and/or Canada.

Physiologically, hunger relates to appetite and is the body’s response to a need for nourishment. Through stomach discomfort or
intestinal rumbling, the body alerts the brain that it requires food. This uneasy sensation is easily addressed with a snack or a full
meal. However, the term “hunger” also relates to a weakened condition that is a consequence of a prolonged lack of food. People
who suffer from this form of hunger typically experience malnourishment, along with poor growth and development.

Hunger
Adequate food intake that meets nutritional requirements is essential to achieve a healthy, productive lifestyle. However, millions
of people in North America, not to mention globally, go hungry and are malnourished each year due to a recurring and involuntary
lack of food. The economic crisis of 2008 caused a dramatic increase in hunger across the United [Link] [Link].
“Hunger in America: 2011 United States Hunger and Poverty Facts.” Accessed October 10, 2011.
[Link]/articles/...nger_facts.htm.

Key Hunger Statistics

In 2010, 925 million people around the world were classified as hungry. Although this was a decrease from a historic high of more
than one billion people from the previous year, it is still an unbearable number. Every night, millions and millions of people go to
sleep hungry due to a lack of the money or resources needed to acquire an adequate amount of food. This graph shows the division
of hungry people around the globe.

Key Hunger Terms

A number of terms are used to categorize and classify hunger. Two key terms, food security and food insecurity, focus on status and
affect hunger statistics. Another term, malnutrition, refers to the deficiencies that a hungry person experiences.

Food Security
Most American households are considered to be food secure, which means they have adequate access to food and consume enough
nutrients to achieve a healthy lifestyle. However, a minority of US households experiences food insecurity at certain points during
the year, which means their access to food is limited due to a lack of money or other resources. This graphic shows the percentage
of food-secure and food-insecure households in the United States during the year 2010.

Food Insecurity
Food insecurity is defined as not having adequate access to food that meets nutritional needs. According to the USDA, about 48.8
million people live in food-insecure households and have reported multiple indications of food access problems. About sixteen
million of those have “very low food security,” which means one or more people in the household were hungry at some point over
the course of a year due to the inability to afford enough food. The difference between low and very low food security is that
members of low insecurity households have reported problems of food access, but have reported only a few instances of reduced
food intake, if [Link]-Jensen, A. et al. “Household Food Security in the United States in 2010.” US Department of
Agriculture, Economic Research Report, no. ERR-125 (September 2011). African American and Hispanic households experience
food insecurity at much higher rates than the national [Link]-Jensen, A. et al. “Household Food Security in the United
States in 2010.” US Department of Agriculture, Economic Research Report, no. ERR-125 (September 2011).
Households with limited resources employ a variety of methods to increase their access to adequate food. Some families purchase
junk food and fast food—cheaper options that are also very unhealthy. Other families who struggle with food security supplement
the groceries they purchase by participating in government assistance programs. They may also obtain food from emergency
providers, such as food banks and soup kitchens in their communities.

16.6.1 [Link]
Malnutrition
A person living in a food-insecure household may suffer from malnutrition, which results from a failure to meet nutrient
requirements. This can occur as a result of consuming too little food or not enough key nutrients. There are two basic types of
malnutrition. The first is macronutrient deficiency and relates to the lack of adequate protein, which is required for cell growth,
maintenance, and repair. The second type of malnutrition is micronutrient deficiency and relates to inadequate vitamin and mineral
[Link] Hunger. “2011 World Hunger and Poverty Facts and Statistics.” Accessed October 10, 2011.
[Link] Even people who are overweight or obese can suffer from this kind of
malnutrition if they eat foods that do not meet all of their nutritional needs.

At-Risk Groups
Worldwide, three main groups are most at risk of hunger: the rural poor in developing nations who also lack access to electricity
and safe drinking water, the urban poor who live in expanding cities and lack the means to buy food, and victims of earthquakes,
hurricanes, and other natural and man-made [Link] and Agriculture Organization of the United Nations. “Hunger:
Frequently Asked Questions.” Accessed October 10, 2011. [Link]/hunger/en/ In the United States, there are additional
subgroups that are at risk and are more likely than others to face hunger and malnutrition. They include low-income families and
the working poor, who are employed but have incomes below the federal poverty level.
Senior citizens are also a major at-risk group. Many elderly people are frail and isolated, which affects their ability to meet their
dietary requirements. In addition, many also have low incomes, limited resources, and difficulty purchasing or preparing food due
to health issues or poor mobility. As a result, more than six million senior citizens in the United States face the threat of hunger.
Meals on Wheels. “Our Vision and Mission.” Accessed October 10, 2011. [Link]/[Link]?pid=299

The Homeless
One of the groups that struggles with hunger are the millions of homeless people across North America. According to a recent study
by the US Conference of Mayors, the majority of reporting cities saw an increase in the number of homeless [Link] United
States Conference of Mayors. “Hunger and Homelessness Survey: A Status Report on Hunger and Homelessness in America’s
Cities, a 27-City Survey.” December 2009. [Link]/pressreleases/up...[Link]. Hunger and homelessness often go
hand-in-hand as homeless families and adults turn to soup kitchens or food pantries or resort to begging for food.

Children
Rising hunger rates in the United States particularly affect children. Nearly one out of four children, or 21.6 percent of all American
children, lives in a food-insecure household and spends at least part of the year [Link]-Jensen, A. et al. “Household Food
Security in the United States in 2010.” US Department of Agriculture, Economic Research Report, no. ERR-125 (September 2011).
Hunger delays their growth and development and affects their educational progress because it is more difficult for hungry or
malnourished students to concentrate in school. In addition, children who are undernourished are more susceptible to contracting
diseases, such as measles and [Link] Hunger. “2011 World Hunger and Poverty Facts and Statistics.” Accessed October
10, 2011.

16.6.2 [Link]
 Going Hungry in America

Video : Going Hungry in America. This video examines the effect of

hunger on many American children.

Government Programs
The federal government has established a number of programs that work to alleviate hunger and ensure that many low-income
families receive the nutrition they require to live a healthy life. A number of programs were strengthened by the passage of the
Healthy, Hunger-Free Kids Act of 2010. This legislation authorized funding and set the policy for several key core programs that
provide a safety net for food-insecure children across the United States.

The Federal Poverty Level

The federal poverty level (FPL) is used to determine eligibility for food-assistance programs. This monetary figure is the minimum
amount that a family would need to acquire shelter, food, clothing, and other necessities. It is calculated based on family size and is
adjusted for annual inflation. Although many people who fall below the FPL are unemployed, the working poor can qualify for
food programs and other forms of public assistance if their income is less than a certain percentage of the federal poverty level,
along with other qualifications.

USDA Food Assistance Programs

Government food and nutrition assistance programs that are organized and operated by the USDA work to increase food security.
They provide low-income households with access to food, the tools for consuming a healthy diet, and education about nutrition.
The USDA monitors the extent and severity of food insecurity via an annual survey. This contributes to the efficiency of food
assistance programs as well as the effectiveness of private charities and other initiatives aimed at reducing food
[Link]-Jensen, A. et al. “Household Food Security in the United States in 2010.” US Department of Agriculture,
Economic Research Report, no. ERR-125 (September 2011).

The Supplemental Nutrition Assistance Program

Formerly known as the Food Stamp Program, the Supplemental Nutrition Assistance Program (SNAP) provides monthly benefits
for low-income households to purchase approved food items at authorized stores. Clients qualify for the program based on
available household income, assets, and certain basic expenses. In an average month, SNAP provides benefits to more than forty
million people in the United [Link]-Jensen, A. et al. “Household Food Security in the United States in 2010.” US
Department of Agriculture, Economic Research Report, no. ERR-125 (September 2011).
The program provides Electronic Benefit Transfers (EBT) which work similarly to a debit card. Clients receive a card with a
certain allocation of money for each month that can be used only for food. In 2010, the average benefit was about $134 per person,
per month and total federal expenditures for the program were $68.2 [Link]-Jensen, A. et al. “Household Food Security in
the United States in 2010.” US Department of Agriculture, Economic Research Report, no. ERR-125 (September 2011).

16.6.3 [Link]
The Special, Supplemental Program for Women, Infants, and Children
The Special, Supplemental Program for Women, Infants and Children (WIC) provides food packages to pregnant and breastfeeding
women, as well as to infants and children up to age five, to promote adequate intake for healthy growth and development. Most
state WIC programs provide vouchers that participants use to acquire supplemental packages at authorized stores. In 2010, WIC
served approximately 9.2 million participants per month at an average monthly cost of about forty-two dollars per [Link]-
Jensen, A. et al. “Household Food Security in the United States in 2010.” US Department of Agriculture, Economic Research
Report, no. ERR-125 (September 2011).

The National School Lunch Program

The National School Lunch Program (NSLP) and School Breakfast Program (SBP) ensure that children in elementary and middle
schools receive at least one healthy meal each school day, or two if both the NSLP and SBP are provided. According to the USDA,
these programs operate in over 101,000 public and nonprofit private schools and residential child-care [Link] Department
of Agriculture. “National School Lunch Program.” October 2011. [Link]/cnd/Lunch/Ab...[Link]. In 2010, the
programs provided meals to an average of 31.6 million children each school day. Fifty-six percent of the lunches served were free,
and an additional 10 percent were provided at reduced prices.

Other Food-Assistance Programs for Children

Other government programs provide meals for children after school hours and during summer breaks. The Child and Adult Care
Food Program (CACFP) offers meals and snacks at child-care centers, daycare homes, and after-school programs. Through
CACFP, more than 3.2 million children and 112,000 adults receive nutritious meals and snacks each [Link] Department of
Agriculture. “Child & Adult Care Food Program.” Last modified June 10, 2011. [Link]/cnd/care/. The Summer Food
Service Program provides meals to children during summer break. Sponsors include day camps and other recreation programs
where at least half of the attendees live in households with incomes below the federal poverty [Link] Department of Agriculture.
“Summer Food Service Program.” [Link] 14 2011r Congressbrary. Last modified July 20, 2011.
[Link] These and other programs help to fill in the gaps during the typical day of a food-
insecure child.

The Head Start Program

Head Start is a health and development program for children ages three to five, from low-income families. The philosophy behind
the organization is that early intervention can help address the educational, social, and nutritional deficiencies that children from
lower-income families often experience. Launched in 1965, it is one of the longest-running, poverty-related programs in the United
States. Today, Head Start programs include education, meals, snacks, and access to other social services and health [Link]
Department of Health and Human Services. “About the Office of Head Start.” Last reviewed February 23, 2011.
[Link]/programs/ohs/about/[Link].

Other Forms of Assistance

Other forms of assistance include locally-operated charitable organizations, such as food banks and food pantries, which acquire
food from local manufacturers, retailers, farmers, and community members to give to low-income families. Neighborhood soup
kitchens provide meals to the homeless and other people in need. These and other organizations are run by nonprofit groups, as
well as religious institutions, to provide an additional safety net for those in need of food.

Meals on Wheels
An organization known as Meals on Wheels delivers meals to elderly people who have difficulty buying or making their own food
because of poor health or limited mobility. It is the oldest and largest program dedicated to addressing the nutritional needs of
senior citizens. Each day, Meals on Wheels volunteers deliver more than one million meals across the United States. The first
Meals on Wheels program began in Philadelphia in the 1950s. In the decades since, the organization has expanded into a vast
network that serves the elderly in all fifty states and several US territories. Today, Meals on Wheels remains committed to ending
hunger among the senior citizen [Link] on Wheels. “The Meals on Wheels Association of America.” Accessed October
10, 2011. [Link]/[Link]?pid=212.

16.6.4 [Link]
 Figure : Delivery of Thanksgiving dinner to a
Meals on Wheels recipient. Clara Donney, (right), a Meals on Wheels recipient of a Thanksgiving dinner sponsored by the Great
Falls Community Food Bank, is all smiles as Airman 1st Class Courtney Taylor, customer service technician with the 341st
Comptroller Squadron, delivers her meal. (Public Domain; US Air Force).

Key Takeaways
Around the world, nearly one billion people suffer the effects of constant hunger. Key terms related to hunger include food security,
which means having continual access to safe, sufficient, nutritious food, and food insecurity, which means not having continual
access to safe, sufficient, nutritious food. There are two types of malnutrition. The first is macronutrient deficiency and relates to
the lack of adequate protein, which is required for cell growth, maintenance, and repair. The second type of malnutrition is
micronutrient deficiency and relates to inadequate vitamin and mineral intake. There are a number of groups at risk for hunger,
including the unemployed and underemployed, poor families, the elderly, and the homeless. The United States has a number of
federal and state programs, as well as local charities, which provide assistance and education for people who fall into the category
of food insecurity.

Discussion Starter
1. Do you believe there are enough government programs currently in place to address the problem of hunger? Why or why not? If
not, what additional solutions would you recommend?

16.6: The Issue of Food Security is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

16.6.5 [Link]
16.7: Nutrition and Your Health
Learning Objectives

Relate the research on home-cooked family meals to comprehensive health and wellness, taste, sustainability, and the
strengthening of family bonds

The adage, “you are what you eat,” seems to be more true today than ever. In recent years, consumers have become more
conscientious about the decisions they make in the supermarket. Organically grown food is the fastest growing segment of the food
industry. Also, farmers’ markets and chains that are health-food-oriented are thriving in many parts of North America. Shoppers
have begun to pay more attention to the effect of food on their health and well-being. That includes not only the kinds of foods that
they purchase, but also the manner in which meals are cooked and consumed. The preparation of food can greatly affect its
nutritional value. Also, studies have shown that eating at a table with family members or friends can promote both health and
happiness.

Family Meals
In the past, families routinely sat down together to eat dinner. But in recent decades, that comfortable tradition has fallen by the
wayside. In 1900, 2 percent of meals were eaten outside of the home. By 2010, that figure had risen to 50 percent. Mark Hyman,
MD, “How Eating at Home Can Save Your Life,” Huffington [Link], 9 January 2011. [Link]
mar...ily-dinner-how _b_806114.html? Today, family members often go their own way at mealtimes and when they do sit down
together, about three times a week, the meal often lasts less than twenty minutes and is spent eating a microwaved meal in front of
a television.
However, recent studies have shown that home-cooked, family meals really matter. Family meals usually lead to the consumption
of healthy food packed with nutrition, rather than an intake of empty calories. Other benefits include strengthening familial bonds,
improving family communication, and helping young children learn table manners. Increased frequency of family meals has also
been associated with certain developmental assets, such as support, boundaries and expectations, commitment to learning, positive
values, and social [Link], M. “Do Family Meals Still Matter?” Visions: Family and Community Health Sciences
(Rutgers University) 21, no. 3 (2009).
Home-prepared meals provide an opportunity for more balanced and better-portioned meals with fewer calories, sodium, and less
saturated fat. When families prepare food together, parents or caregivers can also use the time to teach children about the ways their
dietary selections can affect their health.

The Adolescent Diet

Teenagers’ dietary choices are influenced by their family’s economic status, the availability of food inside and outside the home,
and established traditions. Studies have found links between the prevalence of family meals during adolescence and the
establishment of healthy dietary behaviors by young adulthood. Yet, many of today’s teenagers make food selections on their own,
which often means eating junk food or fast food on the go.
However, adolescents who regularly consume family meals or have done so in the past are more likely to eat breakfast and to eat
more fruits and vegetables. Research has shown that adolescents who have regular meals with their parents are 42 percent less
likely to drink alcohol, 50 percent less likely to smoke cigarettes, and 66 percent less likely to use marijuana. Regular family
dinners also help protect teens from bulimia, anorexia, and diet pills. In addition, the frequency of family meals was inversely
related to lower academic scores and incidents of depression or [Link] Hyman, MD, “How Eating at Home Can Save Your
Life,” Huffington [Link], 9 January 2011. [Link] _b_806114.html?

Sustainable Eating
As discussed at the beginning of this chapter, sustainable agricultural practices provide healthy, nutritious food for the consumers
of today, while preserving natural resources for the consumers of tomorrow. Sustainability not only has economic and
environmental benefits, but also personal benefits, including reduced exposure to pesticides, antibiotics, and growth hormones.
Sustainable eaters do all of the following:

16.7.1 [Link]
 Consume less processed food. People who eat sustainably focus on whole foods that are high in nutritive value, rather than
heavily processed foods with lots of additives.
Eat more home-cooked meals. Sustainable eaters go out to restaurants less often, and when they do, they dine at
establishments that provide dishes made from whole-food ingredients.
Consume a plant-based diet. Research has shown that a plant-based diet, focused on whole grains, vegetables, fruits, and
legumes, greatly reduces the risk of heart disease.
Buy organic food products. Organically produced foods have been cultivated or raised without synthetic pesticides,
antibiotics, or genetic engineering. Certified organic foods can be identified by the USDA’s stamp.
Buy locally grown foods. Buying locally benefits the environment by reducing the fossil fuels needed to transport food from
faraway places. Also, farmers keep eighty to ninety cents for every dollar spent at a farmer’s market.

Disease Prevention and Management

Eating fresh, healthy foods not only stimulates your taste buds, but also can improve your quality of life and help you to live
longer. As discussed, food fuels your body and helps you to maintain a healthy weight. Nutrition also contributes to longevity and
plays an important role in preventing a number of diseases and disorders, from obesity to cardiovascular disease. Some dietary
changes can also help to manage certain chronic conditions, including high blood pressure and diabetes. A doctor or a nutritionist
can provide guidance to determine the dietary changes needed to ensure and maintain your health.

Heart Health
According to the WHO, cardiovascular disease is the leading cause of death on the [Link] Health Organization. “The Top 10
Causes of Death.” Accessed [Link] However, a healthy diet can go a long way
toward preventing a number of conditions that contribute to cardiovascular malfunction, including high levels of blood cholesterol
and narrowed arteries. As discussed in this text, it is extremely helpful to reduce the intake of trans fat, saturated fat, and sodium.
This can considerably lower the risk of cardiovascular disease, or manage further incidents and artery blockages in current heart
patients. It is also beneficial to eat a diet high in fiber and to include more omega-3 fatty acids, such as the kind found in mackerel,
salmon, and other oily fish.

High Blood Pressure

Blood pressure is the force of blood pumping through the arteries. When pressure levels become too high, it results in a condition
known as hypertension, which is asymptomatic but can lead to a number of other problems, including heart attacks, heart failure,
kidney failure, and strokes. For people with high blood pressure, it can be beneficial to follow the same recommendations as those
for heart patients. First of all, it is crucial to reduce the intake of sodium to prevent pressure levels from continuing to rise. It can
also be helpful to increase potassium intake. However, patients should check with a doctor or dietitian first, especially if there are
kidney disease concerns.

Tools for Change

The Dietary Approaches to Stop Hypertension, or DASH diet, is highly recommended to lower blood pressure. This program
promotes an increased intake of potassium and calcium by emphasizing fruits, vegetables, whole grains, low-fat dairy products, and
limited amounts of lean meat. The DASH diet also decreases the intake of saturated fat and sugar. Studies have shown that blood-
pressure patients on the DASH diet were able to reduce their diastolic pressure levels (the lower measurement, which is taken
between beats when the heart is relaxed) by up to 5 mmHg regardless of age, gender, or ethnicity. You can learn more about the
DASH diet at [Link]

Diabetes
The rising rates of diabetes have triggered a health crisis in the United States and around the world. In diabetics, the levels of blood
glucose, or blood sugar, are too high because of the body’s inability to produce insulin or to use it effectively. There are two types
of this disease. Although the causes of Type 1 diabetes are not completely understood, it is known that obesity and genetics are
major factors for Type 2.

16.7.2 [Link]
Nutrition plays a role in lowering the risk of Type 2 diabetes or managing either form of the disease. However, it is a myth that
there is one diabetes diet that every patient should follow. Instead, diabetics should keep track of the foods they consume that
contain carbohydrates to manage and control blood-glucose levels. Also, a dietitian can help patients create a specific meal plan
that fits their preferences, lifestyle, and health goals.

The Crisis of Obesity

Excessive weight gain has become an epidemic. According to the National Institutes of Health, over two-thirds of American adults
are overweight, and one in three is obese. Obesity in particular puts people at risk for a host of complications, including Type 2
diabetes, heart disease, high cholesterol, hypertension, osteoarthritis, and some forms of cancer. The more overweight a person is,
the greater his or her risk of developing life-threatening complications. There is no single cause of obesity and no single way to
treat it. However, a healthy, nutritious diet is generally the first step, including consuming more fruits and vegetables, whole grains,
and lean meats and dairy [Link] Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.
“Overweight and Obesity Statistics.” NIH Publication No. 04-4158. Updated February 2010.
[Link]/publication...s/[Link].

Kidney Disease
Chronic kidney failure is the gradual loss of kidney function and can cause dangerous levels of fluid and waste to build up in the
body. Nutrition is very important in managing end-stage renal disease, and a patient with this condition should discuss a meal plan
with a dietitian and physician. Certain macro- and micronutrients will need to be monitored closely, including protein, potassium,
sodium, and phosphorus. Kidney patients must also keep track of their caloric intake and dietitians may recommend consuming
more fast-releasing carbohydrates and low-saturated fats to boost the number of calories consumed each day.

Cancer
Certain cancers are linked to being overweight or obese. Additionally, some foods are related to either an increased or decreased
risk for certain cancers. Foods linked to decreased cancer risk include whole grains, high-fiber foods, fruits, and vegetables. Foods
linked to increased cancer risk include processed meats and excess alcohol.

Digestive Disorders
Digestive disorders can include constipation, heartburn or gastroesophageal reflux disease, inflammatory bowel disease, including
Crohn’s and ulcerative colitis, and irritable bowel syndrome. These disorders should be addressed with a physician. However, for
many of them, diet can play an important role in prevention and management. For example, getting enough fiber and fluids in your
diet and being active can help to alleviate constipation.

Key Takeaways
More and more consumers are weighing nutritional considerations as they choose which foods to purchase and prepare for their
families. Studies have shown that family meals and home-cooked food not only benefit a person’s health, but also their overall
well-being. Family meals lead to the consumption of healthy food, tighter familial bonds, improved communication, and the
teaching of table manners to young children. Diet plays a key role in the prevention and management of many chronic conditions or
diseases, such as hypertension and diabetes.

Discussion Starter
1. What would you recommend to help people who are struggling with diabetes? What tips would you provide? What lifestyle
changes might help? Use the dietary guidelines at the Mayo Clinic’s website to help provide specific suggestions.
[Link]/health/dia...s-diet/DA00027.

16.7: Nutrition and Your Health is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

16.7.3 [Link]
16.8: Diets around the World
Learning Objectives
Give examples of how local taste preferences and availability influence food choices in different regions of the globe.
Explain what is meant by Alice Waters’ statement: “Food is precious.”

In the past, people’s culture and location determined the foods they ate and the manner in which they prepared their meals. For
example, in the Middle East, wheat was a staple grain and was used to make flatbread and porridge, while halfway around the
world in Mesoamerica, maize was the staple crop and was used to make tortillas and tamales. Today, most people have access to a
wide variety of food and can prepare them any way they choose. However, customs and traditions still strongly influence diet and
cuisine in most areas of the world.

Comparing Diets
There are a multitude of diets across the globe, in all regions and cultures. Each is influenced by the traditions of the past, along
with the produce and livestock available. Local tastes, agricultural economics, and incomes still have a profound effect on what
many people eat around the world. In this section, you will read a few examples of cuisines in different countries and regions,
demonstrating differences in preferences. We will also compare common dietary choices in each region for a key meal—breakfast.

North America
The people of the United States and Canada consume a wide variety of food. Throughout both countries, people enjoy eating all
kinds of cuisine from barbecue, pizza, peanut butter sandwiches, and pie to sushi, tacos, chow mein, and roti (an Indian flatbread).
This is partly due to the influence of immigration. As people emmigrated to North America, they brought their dietary differences
with them. In the 1800s, for example, Italian immigrants continued to cook spaghetti, pesto, and other cultural dishes after arriving
in the United States. Today, Italian cuisine is enjoyed by many Americans from all backgrounds.
The variety of North American cuisine has also been impacted by regional variations. For example, fried chicken, cornbread, and
sweet tea are popular in the southern states, while clam chowder, lobster rolls, and apple cider are enjoyed in New England. Also,
as more people seek to support sustainable agriculture, locally grown crops and whole-food cooking practices often factor into
what Americans eat and how they eat it.

Breakfast in North America

Meals can vary widely from one region of the world to another. Therefore, it can be interesting and informative to compare the
choices made for a particular meal around the globe. Throughout this section, we will explore the kinds of foods that people
consume as they begin their day. Breakfast is a vital meal in any part of the world because it breaks the long overnight fast. An
adequate breakfast also provides fuel for the first part of the day and helps improve concentration and energy levels.
Let’s begin with breakfast in North America. On weekdays, North Americans often eat breakfast in a hurry or on the go. Therefore,
many people choose breakfast foods that are quick and easy to prepare or can be eaten during the trip to school or the office. As a
result, breakfast cereals with milk are extremely popular, and also oatmeal, toast, or bagels. However, on the weekends, some
people spend a longer time enjoying a hearty breakfast or going out for brunch. Typical choices emphasize hot foods and include
egg dishes, such as omelettes and scrambled or fried eggs, along with pancakes, waffles, french toast, bacon or sausage, and orange
juice, coffee, or tea to drink.

Central and South America

Both Central America and South America feature cuisines with rich Latin flavors. In addition, rice and corn are staples in both and
form the basis for many dishes. Both regions are also affected by the mixture of influences from the native populations and the
cultural traditions brought by Spanish and Portuguese immigrants during the 1600s and beyond.
South America has a diverse population, which is reflected in dietary choices across the continent. The northwestern region boasts
some of the most exotic food in Latin America. In northeastern South America, many dishes feature a contrast of sweet and salty
tastes, including raisins, prunes, capers, and olives. Also, rice grown in the area and seafood off the coast are key ingredients in

16.8.1 [Link]
South American-style paella. The north central part of the continent reflects a Spanish influence. Many of the dominant spices—
cumin, oregano, cinnamon, and anise—came from Spain, along with orange and lime juices, wine, and olive oil. The south is cattle
country and the locals enjoy grass-fed beef cooked in the form of asados, which are large cuts roasted in a campfire. Another
popular meat dish is parrilladas, which are thick steaks grilled over [Link] Light. “South American Cuisine.” © 2012 Time
Inc. Lifestyle Group. [Link] -00400000001391/.
From Mexico in the North to Panama in the South, Central American cuisine features some of the world’s favorite foods, including
rice, beans, corn, peppers, and tropical fruits. This area combines a variety of culinary traditions derived from the native Maya and
Aztec populations, arrivals from Spain, and African and Latin-influenced neighbors along the Caribbean. In this region of the
world, tamales are common. Spicy seasonings, including hot chili peppers, are also very popular.

Typical Southern and Central American Foods

Typical foods in South and Central America include quinoa, which is a grain-like crop that is cultivated for its edible seeds. Quinoa
has a high protein and fiber content, is gluten-free, and is particulary tasty cooked in pilafs. Another popular grain product is the
tortilla, which is a flatbread made from wheat or corn. Tortillas are used to make a number of dishes, including burritos, enchiladas,
and tacos. Fruits and vegetables that are common in Mexico, Central America, and South America include corn, avocados, yucca,
peppers, potatoes, mangoes, and papayas. Rice, beans, and a soft cheese known as queso fresco are common to the cuisine in this
area of the world as well.

Figure : Tamales, which are popular in Mexico and parts of

Central and South America, are made from a shell called a masa that is stuffed with meat or vegetables and steamed or boiled in a
wrapper of dried corn leaves. The wrapping is discarded prior to eating. Salvadorean tamales shown above are made in banana or
plantain leaves, and the masa (corn meal) is often seasoned with chicken stock. (Public Domain; Ll1324).

Breakfast in Central America

In this region, the first meal of the day commonly includes huevos rancheros (fried eggs served over a tortilla and topped with
tomato sauce). Other popular breakfast dishes include pan dulce (a sweetened bread), along with fried plantains, and a spicy
sausage called chorizo. The typical beverage is coffee, which is available in many forms, including café con leche (which is
sweetened with lots of milk) and café de olla (with cinnamon and brown sugar). Hot chocolate is also popular and tends to be thick,
rich, and flavored with spices such as cinnamon or achiote. In the Yucatan region, huevos motulenos are prepared by spreading
refried beans onto fresh tortillas with fried eggs, peas, chopped ham, and cheese.

Europe
European cuisine is extremely diverse. The diet in Great Britain is different from what people typically consume in Germany, for
example. However, across the continent, meat dishes are prominent, along with an emphasis on sauces. Potatoes, wheat, and dairy
products are also staples of the European diet.
The nations along the Mediterranean Sea are particularly renowned for their flavorful food. This part of the world boasts a number
of famous dishes associated with their countries of origin. They include Italy’s pasta, France’s coq au vin, and Spain’s paella.

16.8.2 [Link]
Italy
Although Italy is a relatively small nation, the difference in cuisine from one region to another can be great. For example, the
people of northern Italy tend to rely on dairy products such as butter, cream, and cheeses made from cow’s milk, because the land is
flatter and better suited to raising cattle. In southern Italy, there is greater reliance on olive oil than butter, and cheeses are more
likely to be made from sheep’s [Link] Light. “Regional Italian Cuisine.” © 2012 Time Inc. Lifestyle Group.
[Link] -00400000001340/.
However, there are a number of common ingredients and dishes across the country. Italian cuisine includes a variety of pasta, such
as spaghetti, linguine, penne, and ravioli. Other well-known dishes are pizza, risotto, and polenta. Italians are also known for
cooking with certain spices, including garlic, oregano, and basil.

France
For centuries, the French have been famous for their rich, extravagant cuisine. Butter, olive oil, pork fat, goose fat, and duck fat are
all key ingredients. Common French dishes include quiche, fondue, baguettes, and also creams and tarts. Frites, or French fries, are
cut in different shapes and fried in different fats, depending on the region. Fresh-baked bread is also found across the nation from
the skinny baguettes of Paris to the sourdough breads in other parts of the country.
Every region of France seems to have its version of coq au vin (braised chicken most often cooked with garlic, mushrooms, and
pork fat in wine). For instance, in the northeast, the dish is prepared a la biere (in beer). In Normandy in the northwest, coq au vin
is cooked au cidre (in apple cider).Cooking Light. “France’s Regional Cuisine.” © 2012 Time Inc. Lifestyle Group.
[Link] -00400000001365/.

Spain
One of the most popular Spanish dishes is paella, a gumbo of rice, seafood, green vegetables, beans, and various meats. The
ingredients can vary wildly from one region to another, but rice is always the staple of the dish. Spain is also renowned for its tapas,
which are appetizers or snacks. In restaurants that specialize in preparing and serving tapas, diners often order a number of different
dishes from a lengthy menu and combine them to make a full meal.
Cooks in Spain rely on a variety of olive oils known for their flavors, ranging from smooth and subtle to fruity and robust. Spanish
cuisine combines Roman, Moorish, and New World flavors. Key ingredients include rice, paprika, saffron, chorizo, and citrus
[Link] Light. “Spanish Flavor.” © 2012 Time Inc. Lifestyle Group. [Link]
-00400000001203/.

The Mediterranean Diet

Video : The Mediterranean Diet. This video shows the cultural history of
the cuisine enjoyed by many people who live in the Mediterranean region of
Europe.

16.8.3 [Link]
Breakfast in Europe
In some countries, such as France, Italy, and Belgium, coffee and bread are common breakfast foods. However, the people of Great
Britain and Ireland tend to enjoy a bigger breakfast with oatmeal or cold cereal, along with meats like bacon and sausage, plus eggs
and toast. Tea is also popular in this area, not only for breakfast, but throughout the day. The continental-style breakfast is most
commonly associated with France and includes fresh-baked croissants, toast, or a rich French pastry called brioche, along with a
hot cup of tea, coffee, or café au lait.

Africa
The continent of Africa is home to many different countries and cultural groups. This diversity is reflected in the cuisine and
dietary choices of the African people. Traditionally, various African cusines combine locally grown cereals and grains, with fruits
and vegetables. In some regions, dairy products dominate, while in others meat and poultry form the basis of many dishes.

Ethiopia
Ethiopia, located along the Horn of Africa, is one of the few African countries never colonized by a foreign nation prior to the
modern era. So, outside influences on the culture were limited. Religious influences from Jewish, Islamic, and Catholic traditions
played a larger role on the shaping of Ethiopian cuisine, because of the need to adhere to different dietary restrictions. For example,
approximately half of Ethiopians are Muslim and must abstain from eating pork or using spices and nuts to flavor dishes. Ethiopia
is also known for dishes that use local herbs and spices, including fenugreek, cumin, cardamom, coriander, saffron, and mustard.
Many dishes also reflect a history of vegetarian cooking since meat was not always readily [Link] Light. “Ethiopian
Tastes.” © 2012 Time Inc. Lifestyle Group. [Link]
In addition, Ethiopians use their hands to eat. First, diners tear off pieces of injera, a spongy, tangy flatbread made from teff flour.
Then, they use the pieces as utensils to scoop up vegetables, legumes, and meats from a communal [Link] [Link].
“Injera.” © 2004–2012. [Link] Teff is a grass that grows in the highlands of Ethiopia and
is a staple of the diet.

Central and West Africa

Stretching from mountains in the north to the Congo River, Central Africa primarily features traditional cuisine. Meals are focused
on certain staples, including cassava, which is a mashed root vegetable, and also plantains, peanuts, and chili peppers. In West
Africa, which includes the Sahara Desert and Atlantic coast, the cuisine features dishes made from tomatoes, onions, chili peppers,
and palm nut oil. Popular dishes in both regions include stews and porridges, such as ground nut stew made from peanuts, and also
fufu, a paste made from cassava or maize.

Breakfast in Africa
African breakfast choices are strongly influenced by the colonial heritage of a region. The people of West Africa typically enjoy the
French continental-style breakfast. However, in the eastern and southern parts of the continent, the traditional English breakfast is
more common. In North Africa, breakfast is likely to include tea or coffee, with breads made from sorghum or millet. In East and
West Africa, a common breakfast dish is uji, a thick porridge made from cassava, millet, rice, or corn. Kitoza is a delicacy made
from dried strips of beef that are eaten with porridge in Madagascar. In Algeria, French bread, jam, and coffee is a typical breakfast.
The people of Cameroon eat beignets, which is a doughnut eaten with beans or dipped in a sticky, sugary liquid called bouilli.

Asia
Asia is a massive continent that encompasses the countries of the Middle East, parts of Russia, and the island nations of the
southeast. Due to this diversity, Asian cuisine can be broken down into several regional styles, including South Asia, which is
represented for our purposes here by India, and East Asia which is represented for our purposes by China, Korea, and Japan. Even
with this variety, the Asian nations have some dietary choices in common. For example, rice is a staple used in many dishes across
the continent.

16.8.4 [Link]
India
In India, there is much variety between the different provinces. The nation’s many kinds of regional cuisines can date back
thousands of years and are influenced by geography, food availability, economics, and local customs. However, vegetarian diets are
common across the nation for religious reasons, among others. As a result, Indian dishes are often based on rice, lentils, and
vegetables, rather than meat or poultry. Indian cooking also features spicy seasonings, including curries, mustard oil, cumin, chili
pepper, garlic, ginger, and garam masala, which is a blend of several [Link] [Link]. “Guide to Easy Indian Recipes,
Curry Recipes and Curry Spices.” © 2009. [Link]/. India is also known for its breads, including the flatbreads roti
and chapati. Dishes that are popular not only in India but around the world include samosa, a potato-stuffed pastry; shahi paneer, a
creamy curry dish made out of soft cheese and tomato sauce; and chana masala, chickpeas in curry [Link]. “Your
Guide to Indian Food.” © 2003–2011. [Link]

China
China has the world’s most sizable population. As a result, there are many different culinary traditions across this vast country,
which is usually divided into eight distinct cuisine regions. For example, Cantonese cuisine, which is also known as Guangdong,
features light, mellow dishes that are often made with sauces, including sweet-and-sour sauce and oyster sauce. Cantonese-style
cuisine has been popularized in Chinese restaurants around the world. Another cuisine is known as Zhejiang, which is often
shortened to Zhe, and originates from a province in southern China. It features dishes made from seafood, freshwater fish, and
bamboo [Link]. “China’s Eight Cuisines Revealed and How to Identify Them.” ©2008–2011
[Link]/expat-co...sines-revealed -[Link] Key ingredients that are used in several, but not
all, of the different regions include rice, tofu, ginger, and garlic. Tea is also a popular choice in most parts of the country.
Chinese use chopsticks as utensils. These small tapered sticks can be made from a variety of materials, including wood, plastic,
bamboo, metal, bone, and ivory. Both chopsticks are held in one hand, between the thumb and fingers, and are used to pick up
food.

Korea
Korean cuisine is primarily centered around rice, vegetables, and meat. Commonly-used ingredients include sesame oil, soy sauce,
bean paste, garlic, ginger, and red pepper. Most meals feature a number of side dishes, along with a bowl of steam-cooked, short
grain rice. Kimchi, a fermented cabbage dish, is the most common side dish served in Korea and is consumed at almost every meal.
Another signature dish, bibimbap, is a bowl of white rice topped with sautéed vegetables and chili pepper paste and can include egg
or sliced meat. Bulgogi consists of marinated, barbecued [Link] Tourism Organization. “Food in Korea.” Accessed October 10,
2011. [Link]/enu/1051_Food.jsp.

Japan
As in other parts of Asia, rice is a staple in Japan, along with seafood, which is plentiful on this island nation. Other commonly-
used ingredients include noodles, teriyaki sauce, dried seaweed, mushrooms and other vegetables, meat, and miso, which is
soybean paste. Some favorite foods include the raw fish dishes sashimi and sushi, which are not only popular in Japan, but are also
around the world. Typical beverages include green tea and also sake, which is a wine made of fermented [Link] MD. “Diets of
the World: The Japanese Diet.” © 2005–2011. [Link]
The traditional table setting in Japan includes placing a bowl of rice on the left and a bowl of miso soup on the right side. Behind
the rice and the soup are three flat plates which hold the accompanying side dishes. Similar to China, chopsticks are used in Japan
and are generally placed at the front of the table setting. At school or work, many Japanese people eat out of a bento lunch box,
which is a single-portion takeout or home-cooked meal. Bento boxes typically include rice, fish or meat, and cooked or pickled
vegetables.

The Middle East

Middle Eastern cuisine encompasses a number of different cooking styles from Asian countries along the Mediterranean, as well as
from North African nations, such as Egypt and Libya. In this part of the world, lamb is the most commonly consumed meat and is
prepared in a number of ways, including as a shish kebab, in a stew, or spit-roasted. However, kosher beef, kosher poultry, and fish

16.8.5 [Link]
are eaten as well. Other staples include the fruits and vegetables that grow in the hills of many Middle Eastern countries, such as
dates, olives, figs, apricots, cucumber, cabbage, potatoes, and eggplant. Common grains include couscous, millet, rice, and bulghur.
Popular dishes include Syrian baba ganoush, which is pureed eggplant, and kibbeh, or lamb with bulghur wheat, from
[Link]. “Middle Eastern Recipes.” Accessed December 5, 2011. [Link]/solrSearchResu...le\%20Eastern&
sitesection=recipes. A flatbread called pita served with hummus, or pureed chickpeas, is another popular dish in this region of the
world.
Most people who reside in the Arab countries of the Middle East are Muslim, which can affect their diet. Many Muslims do not
consume alcohol or pork. They also observe certain diet-related religious traditions, such as a daytime fast during the month of
Ramadan. Other residents of the Middle East include Jews and Christians, and their traditions also affect what foods they eat and
how they prepare it. For example, many Jews in Israel keep kosher and follow a set of dietary laws that impact food choices,
storage, and preparation.

Breakfast in Asia
To continue the comparison of breakfast around the world, let’s examine the first meal of the day in many parts of Asia. In India,
the first meal of the day commonly includes eggs scrambled with spices, potatoes, and onions, as well as fresh fruit and yogurt.
Breakfast in China often consists of rice complemented by vegetables, meat, or fish. In Korea, a traditional breakfast would include
soup made of either beef ribs or pork intestines, a selection of bread and pastries, rice, and kimchi, which is believed to promote
intestinal health. Breakfast in Japan does not greatly differ from any other meal. It typically consists of a bowl of steamed white
rice, a small piece of fish, a bowl of miso soup with tofu, vegetables, green tea, and occasionally pickled plums called umeboshi.
Hot bowls of noodles in broth topped with pork slices, scallions, and bamboo shoots are also common.

Figure : In the different regions of China, congee is prepared

with various types of rice, which results in different consistencies. In Japan, Nanakusa-gayu ( 七草粥 ), seven-herb porridge. (CC
BY-SA 3.0; Blue Lotus).
Congee is a common breakfast food across Asia. This dish is a porridge made of rice that is consumed in a number of Asian
countries, including Vietnam, Thailand, Burma, and Bangladesh. Congee can be prepared both savory and sweet and contain a
variety of ingredients, usually meats, vegetables, and herbs. It can be eaten alone or served as a side dish.

The Diversity of Palates and Habits

Around the globe, people enjoy different foods and different flavors. In some cultures, the main dishes are meat-based, while others
focus on plant-based meals. You can also find different staples in different regions of the world, including rice, potatoes, pasta,
corn, beans, root vegetables, and many kinds of grains. Different flavors are also popular on different parts of the planet, from
sweet to salty to sour to spicy.

16.8.6 [Link]
Food Availability
People tend to eat what grows or lives nearby. For example, people in coastal areas tend to consume more seafood, while those in
inland areas tend to structure their diet around locally-grown crops, such as potatoes or wheat. In many developing countries, a
large part of the diet is composed of cereal grains, starchy roots, and legumes. However, a number of common staples are
consumed worldwide, including rice, corn, wheat, potatoes, cassava, and beans.

Income and Consumption

In addition to regional dissimilarities in diets, income also plays a major role in what foods people eat and how they prepare them.
The average global calorie consumption has increased to record levels in recent years. This is a consequence of rising incomes,
which have allowed consumers in many regions to expand both the variety and the quantity of food they eat. Among developing
countries, the daily intake of calories per person rose by nearly 25 percent from the early 1970s to the [Link] Department of
Agriculture, Foreign Agricultural Service. “Diets Around the World: How the Menu Varies.” Last modified October 14, 2004.
[Link]/info/agexpor.../Apr/[Link]., Centers for Disease Control and Prevention. “Caloric Consumption on the Rise in
the United States, Particularly Among Women.” NCHS Press Room, February 5, 2004.
[Link] People in the western world were able to increase their consumption of
meat and poultry, fruits and vegetables, and fats and oils. However, those gains were minimal in the poorest countries, where many
continue to struggle with hunger and a limited [Link] Department of Agriculture, Foreign Agricultural Service. “Diets Around the
World: How the Menu Varies.” Last modified October 14, 2004. [Link]/info/agexpor.../Apr/[Link].

Different Ways of Eating

People from different parts of the world consume their food in different ways and what is common in one country may be
considered impolite in another. For example, in some areas people eat with their fingers, while in others using a fork is much more
acceptable. In some regions of the world, people slurp their soup, while in others they quietly sip it. In some places, diners eat off
of individual plates, while in others people sit at a table with a large communal plate from which everyone eats.
No matter where you travel, you will find that food production, purchase, and preparation affect all facets of life, from health and
economics to religion and culture. Therefore, it is vital for people from all walks of life to consider the choices they make regarding
food, and how those decisions affect not only their bodies, but also their world. Alice Waters, an influential chef and founder of the
nonprofit program Edible Schoolyard, as well as an advocate for sustainable production and consumption, has said, “Remember
food is precious. Good food can only come from good ingredients. Its proper price includes the cost of preserving the environment
and paying fairly for the labor of the people who produce it. Food should never be taken for granted.”Waters, A. “The Art of
Eating.” [Link]. March 31, 2009. [Link]

Alice Waters: Edible Education

Figure : Alice Waters: Edible Education. In this video, Edible Schoolyard founder Alice Waters talks about the value of
growing a garden and learning about food.

16.8.7 [Link]
Key Takeaways
Many people around the world have access to a wide variety of food and can prepare it any way they choose. However, cuisine
remains strongly influenced by location, culture, tradition, and economics. People from all cultures and all walks of life should
consider the choices they make regarding food, and how those decisions affect not only their bodies, but also the world.

Discussion Starter
1. Compare and contrast breakfast in different parts of the world. What are common attitudes about the first meal of the day? How
are the choices that people make the same? How are they different? Are there any breakfast dishes in common?

16.8: Diets around the World is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by LibreTexts.

16.8.8 [Link]
16.E: Food Politics and Perspectives (Exercise)
It’s Your Turn
1. Visit a store and study the labels for one kind of processed food. List all of the additives it contains and research them at the
library or on the Internet. Why was each substance included during the processing stage?
2. Create a brochure for tourists to explain the kinds of foods they can expect to encounter in one region of the world. Reference a
few popular dishes and a few considerations they might need to keep in mind during their travels.
3. How can you move toward a more sustainable diet? Make a list of the kinds of changes you could make to the foods you choose
and the ways you prepare them.

Apply It
1. Create a short newsletter for parents explaining the value of home-cooked, family meals. Describe how sitting down together
for a few meals each week can benefit different members of the family. You may also wish to include one or two tips that
parents can use to encourage their children to make mealtimes a priority.
2. Plan a website that addresses the rising price of food around the world. Describe the look and focus of the main page, along
with subsections that you will include. Also provide links to related material already available online.
3. Research one of the different cuisines described in this chapter, such as the Indian or Ethiopian diet. Explore the history of the
diet, along with the climate, soil, and other factors that affect the foods that farmers grow and how consumers prepare them.
Then create a report to explain your findings.

Expand Your Knowledge

1. Write a short script for a public service announcement that explains the benefits and risks of food additives. What do you
believe the public should know about the natural and synthetic substances that are introduced to foods during the processing
stage?
2. Summarize in a written discussion why economic experts believe the era of cheap food is over. What factors have contributed to
rising food prices around the globe?
3. Draw a comic strip that shows the different facets of a food system for a particular crop, from production to consumption.

16.E: Food Politics and Perspectives (Exercise) is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by
LibreTexts.

16.E.1 [Link]
Index
A D O
absorption digestion osteoporosis
3.4.1: Digestion and Absorption 3.4.1: Digestion and Absorption 9.2.4: Osteoporosis
Adequate Intakes (AI) [Link]: Risk Factors for Osteoporosis
2.6: Understanding Dietary Reference Intakes (DRI) E
Estimated Average Requirements (EARs) P
B 2.6: Understanding Dietary Reference Intakes (DRI) portion size
Bone Densitometry Scan 2.10: When Enough is Enough
9.2.2: Bone Mineral Density is an Indicator of Bone F
Health food security R
Bone mineral density (BMD) 16.6: The Issue of Food Security recommended dietary allowances (RDA)
9.2.2: Bone Mineral Density is an Indicator of Bone 2.6: Understanding Dietary Reference Intakes (DRI)
Health
K
kyphosis T
C Tolerable Upper Intake Levels (UL)
9.2.4: Osteoporosis
calcium 2.6: Understanding Dietary Reference Intakes (DRI)
9.2.3: Micronutrients Essential for Bone Health-
Calcium and Vitamin D
L
lipoproteins W
cancellous bone
5.10: Understanding Blood Cholesterol and Heart Wolff’s law
9.2.1: Bone Structure and Function
Attack Risk 9.2.1: Bone Structure and Function
cholesterol
5.10: Understanding Blood Cholesterol and Heart
Attack Risk
M
chyme malnutrition
3.4.1: Digestion and Absorption 16.6: The Issue of Food Security
cortical bone microvilli
9.2.1: Bone Structure and Function 3.4.1: Digestion and Absorption

1 [Link]
Glossary
Sample Word 1 | Sample Definition 1

1 [Link]
Detailed Licensing
Overview
Title: Introduction to Nutrition Science
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2 [Link]
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SA 4.0 14.3: Infancy - CC BY-NC-SA 4.0
12.2: Comparing Diets - CC BY-NC-SA 4.0 14.4: Toddler Years - CC BY-NC-SA 4.0
12.3: Calories In Versus Calories Out - CC BY-NC-SA 15: Lifespan Nutrition in Adulthood - CC BY-NC-SA 4.0
4.0 15.1: Introduction to Lifespan Nutrition in Adulthood
12.4: Nutrition, Health and Disease - CC BY-NC-SA - CC BY-NC-SA 4.0
4.0 15.2: Young Adulthood - CC BY-NC-SA 4.0
12.5: Threats to Health - CC BY-NC-SA 4.0 15.3: Middle Age - CC BY-NC-SA 4.0
12.6: Undernutrition, Overnutrition, and Malnutrition 15.4: Older Adulthood- The Golden Years - CC BY-
- CC BY-NC-SA 4.0 NC-SA 4.0
12.7: Food Insecurity - CC BY-NC-SA 4.0 16: Food Politics and Perspectives - CC BY-NC-SA 4.0
12.8: Careers in Nutrition - CC BY-NC-SA 4.0
16.1: Prelude to Food Politics and Perspectives - CC
13: Performance Nutrition - CC BY-NC-SA 4.0
BY-NC-SA 4.0
13.1: Introduction to Performance Nutrition - CC BY- 16.2: Historical Perspectives on Food - CC BY-NC-SA
NC-SA 4.0 4.0
13.2: The Essential Elements of Physical Fitness - CC 16.3: The Food Industry - CC BY-NC-SA 4.0
BY-NC-SA 4.0 16.4: The Politics of Food - CC BY-NC-SA 4.0
13.3: The Benefits of Physical Activity - CC BY-NC- 16.5: Food Cost and Inflation - CC BY-NC-SA 4.0
SA 4.0 16.6: The Issue of Food Security - CC BY-NC-SA 4.0
13.4: Fuel Sources - CC BY-NC-SA 4.0
16.7: Nutrition and Your Health - CC BY-NC-SA 4.0
13.5: Sports Nutrition - CC BY-NC-SA 4.0
16.8: Diets around the World - CC BY-NC-SA 4.0
13.6: Water and Electrolyte Needs - CC BY-NC-SA
16.E: Food Politics and Perspectives (Exercise) - CC
4.0
BY-NC-SA 4.0
13.7: Food Supplements and Food Replacements -
Back Matter - CC BY-NC-SA 4.0
CC BY-NC-SA 4.0
Index - CC BY-NC-SA 4.0
14: Lifespan Nutrition From Pregnancy to the Toddler
Glossary - CC BY-NC-SA 4.0
Years - CC BY-NC-SA 4.0
Detailed Licensing - CC BY-NC-SA 4.0
14.1: Introduction to Lifespan Nutrition From
Pregnancy to the Toddler Years - CC BY-NC-SA 4.0

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