Human Nutrition 2020

Human Nutrition: 2020 Edition
Human Nutrition: 2020

Edition
UNIVERSITY OF HAWAI‘I AT MĀNOA

FOOD SCIENCE AND HUMAN
NUTRITION PROGRAM
ALAN TITCHENAL, SKYLAR HARA,

NOEMI ARCEO CAACBAY, WILLIAM
MEINKE-LAU, YA-YUN YANG, MARIE
KAINOA FIALKOWSKI REVILLA,
JENNIFER DRAPER, GEMADY
LANGFELDER, CHERYL GIBBY, CHYNA
NICOLE CHUN, AND ALLISON
CALABRESE
Human Nutrition: 2020 Edition by University of Hawai‘i at Mānoa Food Science and
Human Nutrition Program is licensed under a Creative Commons Attribution 4.0
International License, except where otherwise noted.
Contents
Preface xxv
University of Hawai‘i at Mānoa Food Science and
Human Nutrition Program and Human Nutrition
Program
About the Contributors xxvi

Program
Acknowledgements xl
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Part I. Chapter 1. Basic Concepts in Nutrition
Introduction 3
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Food Quality 14
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Units of Measure 18
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Lifestyles and Nutrition 21
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Achieving a Healthy Diet 30
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Research and the Scientific Method 34
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Types of Scientific Studies 41
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Part II. Chapter 2. The Human Body
Introduction 55
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Basic Biology, Anatomy, and Physiology 62
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The Digestive System 68
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The Cardiovascular System 82
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Central Nervous System 94
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The Respiratory System 99
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The Endocrine System 106
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The Urinary System 110
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The Muscular System 117
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The Skeletal System 120
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The Immune System 129
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Indicators of Health: Body Mass Index, Body Fat 133
Content, and Fat Distribution
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Part III. Chapter 3. Water and Electrolytes
Introduction 145
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Overview of Fluid and Electrolyte Balance 150
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Water’s Importance to Vitality 156
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Regulation of Water Balance 162
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Electrolytes Important for Fluid Balance 172
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Sodium 176
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Chloride 190
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Potassium 195
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Consequences of Deficiency or Excess 199
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Water Concerns 209
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Popular Beverage Choices 216
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Part IV. Chapter 4. Carbohydrates
Introduction 229
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Digestion and Absorption of Carbohydrates 240
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The Functions of Carbohydrates in the Body 253
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Health Consequences and Benefits of High- 260
Carbohydrate Diets
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Carbohydrates and Personal Diet Choices 271
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Part V. Chapter 5. Lipids
Introduction 291
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The Functions of Lipids in the Body 296
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The Role of Lipids in Food 301
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How Lipids Work 305
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Nonessential and Essential Fatty Acids 313
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Digestion and Absorption of Lipids 319
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Tools for Change 331
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Lipids and the Food Industry 340
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Lipids and Disease 345
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A Personal Choice about Lipids 351
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Part VI. Chapter 6. Protein
Introduction 359
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Defining Protein 363
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The Role of Proteins in Foods: Cooking and 374
Denaturation
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Protein Digestion and Absorption 378
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Protein’s Functions in the Body 383
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Diseases Involving Proteins 395
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Proteins in a Nutshell 405
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Proteins, Diet, and Personal Choices 409
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Part VII. Chapter 7. Alcohol
Introduction 431
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Alcohol Metabolism 436
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Health Consequences of Alcohol Abuse 442
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Health Benefits of Moderate Alcohol Intake 448
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Part VIII. Chapter 8. Energy
Introduction 453
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The Atom 460
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Weight Management 472
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Factors Affecting Energy Intake 485
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Factors Affecting Energy Expenditure 492
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Dietary, Behavioral, and Physical Activity 501
Recommendations for Weight Management
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Part IX. Chapter 9. Vitamins
Introduction 515
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Fat-Soluble Vitamins 521
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Water-Soluble Vitamins 550
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Antioxidants 593
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The Body’s Offense 597
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Phytochemicals 600
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Part X. Chapter 10. Major Minerals
Introduction 609
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Calcium 613
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Phosphorus 631
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Sulfur 635
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Magnesium 640
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Summary of Major Minerals 645
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Part XI. Chapter 11. Trace Minerals
Introduction 651
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Iron 655
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Copper 666
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Zinc 671
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Selenium 675
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Iodine 681
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Chromium 686
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Manganese 689
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Molybdenum 692
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Fluoride 695
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Summary of Trace Minerals 700
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Part XII. Chapter 12. Nutrition Applications
Introduction 707
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Understanding Dietary Reference Intakes 710
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Discovering Nutrition Facts 718
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Building Healthy Eating Patterns 740
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MyPlate Planner 745
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Pacific Based Dietary Guidelines 760
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Understanding the Bigger Picture of Dietary 768
Guidelines
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Part XIII. Chapter 13. Lifespan Nutrition From

Pregnancy to the Toddler Years
Introduction 779
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Pregnancy 785
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Infancy 807
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Toddler Years 852
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Part XIV. Chapter 14. Lifespan Nutrition During

Childhood and Adolescence
Introduction 867
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Childhood 871
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Adolescence 884
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Late Adolescence 889
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Part XV. Chapter 15. Lifespan Nutrition in
Adulthood
Introduction 903
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Young Adulthood 907
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Middle Age 913
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Older Adulthood: The Golden Years 919
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Part XVI. Chapter 16. Performance Nutrition
Introduction 933
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The Essential Elements of Physical Fitness 936
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The Benefits of Physical Activity 945
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Fuel Sources 950
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Sports Nutrition 959
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Water and Electrolyte Needs 972
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Food Supplements and Food Replacements 977
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Part XVII. Chapter 17. Food Safety
Introduction 987
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The Major Types of Foodborne Illness 992
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The Causes of Food Contamination 997
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Protecting the Public Health 1011
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The Food System 1017
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Food Preservation 1019
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Food Processing 1025
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The Effect of New Technologies 1030
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Efforts on the Consumer Level: What You Can Do 1034
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Part XVIII. Chapter 18. Nutritional Issues
Introduction 1043
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Comparing Diets 1046
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1. Calories In Versus Calories Out 1063
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Nutrition, Health and Disease 1076
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Threats to Health 1098
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Undernutrition, Overnutrition, and Malnutrition 1121
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Food Insecurity 1132
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Careers in Nutrition 1143
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Part XIX. Appendices
Appendix A 1151
Appendix A
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Appendix B 1156
Attributions
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Preface
UNIVERSITY OF HAWAI‘I AT MĀNOA FOOD SCIENCE AND HUMAN
NUTRITION PROGRAM AND HUMAN NUTRITION PROGRAM
‘A‘ohe pau ka ‘ike i ka hālau ho‘okahi

Knowledge isn’t taught in all one place
This open access textbook was developed as an introductory

nutrition resource to reflect the diverse dietary patterns of people
in Hawai‘i and the greater Pacific. Using the ‘ōlelo no‘eau, or
Hawaiian proverb, stated above, we believe that the principles of
nutrition should be taught through the context of our communities
and environments. Its intended audience are students from the
University of Hawai‘i at Mānoa enrolled in the Food Science and
Human Nutrition (FSHN) 185 course, The Science of Human
Nutrition. However, this open access textbook may be of interest
to other courses interested in teaching nutrition through a Hawai‘i-
Pacific framed lens. This book is best viewed online using the
pressbooks format however, multiple formats (e.g., pdf, epub, mobi)
are also made available.
Preface | xxv
About the Contributors
This open access textbook was made possible through the

collaboration of faculty, students and staff at the University of
Hawai‘i at Mānoa demonstrating the value of working together,
ho‘okahi ka ‘ilau like ana.
Faculty
Jennifer Draper
xxvi | About the Contributors

Jennifer Draper is a Lecturer in the Department of Human
Nutrition, Food and Animal Sciences. She received her MA in
Nutrition Science from the University of Texas at Austin. She is
a Registered Dietitian in private practice specializing in eating
disorders and emotional over-eating. She enjoys interacting with
students and is passionate about helping people have a healthy
relationship with food and their bodies.
Marie Kainoa Fialkowski Revilla
Marie Kainoa Fialkowski Revilla is a Native Hawaiian faculty

member in the Department of Human Nutrition, Food, and Animal
Sciences at the University of Hawai‘i at Mānoa. She teaches a
number of courses in nutrition both face to face and online. She
is dedicated to developing readily available and accessible nutrition
education materials and curricula that reflect Hawai‘i and the
Pacific to ensure that her students can relate to the content being
learned. She enjoys spending time with her ‘ohana (family) at their
home in Ahuimanu on the island of O‘ahu.
About the Contributors | xxvii

Alan Titchenal
Dr. Titchenal received a PhD in nutrition from the University

of California at Davis with emphasis on exercise physiology and
physiological chemistry. His work at the University of Hawai‘i at
Mānoa has focused on the broad areas of nutrition and human
performance and translation of nutrition science for public
consumption. This has included the “Got Nutrients?” project that
provides daily messages on topics related to nutrition, fitness, and
health and the publication of over 600 articles in the Honolulu Star-
Advertiser newspaper.
xxviii | About the Contributors

Students
Noemi Arceo Caacbay
Noemi Arceo Caacbay is a Masters Student in the Public Health,

Health Policy and Management Program at the University of Hawai‘i
at Mānoa. She enjoys learning about all things health-science
related. She is passionate about returning to her home of Saipan,
CNMI where she will give back and serve her community.
About the Contributors | xxix

Allison Calabrese
Allison Calabrese is currently a MS graduate student in the

Nutritional Sciences Program at University of Hawai‘i at Mānoa. She
obtained her BS from California Lutheran University in Exercise
Science with an emphasis in Health Professions. Her research
interests include the relationship between diet and optimal health.
xxx | About the Contributors

Chynna Nicole Chun
Chynna Chun is an undergraduate student majoring in Tropical

Agriculture and the Environment (TAE) with a specialty in plant
production and management at the University of Hawai‘i at Mānoa.
She also serves as a student assistant at the CTAHR Academic and
Student Affairs Office (ASAO) and the 2019-2020 Future Farmers of
America Hawai‘i State Treasurer.
About the Contributors | xxxi

Cheryl Gibby
Cheryl Gibby was born and raised in Hawai‘i and is a wife and
mother of three. She received her BA, MS in Nutritional Sciences,
and PhD in Nutrition from the University of Hawai‘i at Mānoa. She
has served as an instructor for the introductory Nutrition course
at the University of Hawai‘i at Mānoa, and her research interests
include infant and child health, dental and bone health, mobile
health interventions, school nutrition policies, and online
education.
xxxii | About the Contributors

Skylar Hara
Skylar Hara is an undergraduate student student in the Tropical

Agriculture and the Environment program at the University of
Hawai‘i at Mānoa. She has a growing love for plants and hopes to go
to graduate school to conduct research in the future.
About the Contributors | xxxiii

Gemady Langfelder
Gemady Langfelder is an undergraduate dietetics student at the

University of Hawai‘i at Mānoa. She is an ACSM certified personal
trainer and a novice horticulturist. Her interests are nutritional
epidemiology, infant and pre-/post-natal nutrition, and health
policy.
xxxiv | About the Contributors

Ya-Yun Yang
Ya-Yun is a Graduate Assistant in the Distance Education Program

for the College of Tropical Agriculture and Human Resources. She is
currently a PhD student in Learning Design and Technology (LTEC)
at the University of Hawai‘i at Mānoa.
Christina Gar Lai Young
About the Contributors | xxxv

Christina Gar Lai Young is currently an undergraduate student
in Dietetics at the College of Tropical Agriculture and Human
Resources at the University of Hawaiʻi at Mānoa. She plans to
become a Registered Dietitian after obtaining her undergraduate
degree and completing her supervised practice in dietetics.
Staff
Ty Lim
Ty Lim is an instructional designer who received his MA in

Education and BA in Anthropology. He is excited about helping to
create open educational resources for FSHN and CTAHR.
xxxvi | About the Contributors

Billy Meinke
Billy is the Open Educational Resources Technologist for the

Outreach College at the University of Hawai‘i at Mānoa.
About the Contributors | xxxvii

Kellie Taguchi
Kellie is the Distance Education Coordinator for the College of

Tropical Agriculture and Human Resources at the University of
Hawai‘i at Mānoa.
Contact Person
Dr. Marie Kainoa Fialkowski Revilla

[email protected]
808-956-8337
1955 East West Road
Honolulu, HI 96822
University of Hawaii at Manoa
Department of Human Nutrition, Food, and Animal Sciences
xxxviii | About the Contributors

Note to Educators Using this Resource
Please send edits and suggestions directly to Dr. Fialkowski Revilla

on how we may improve the textbook. We also welcome others to
adopt the book for their own course needs, however, we would like
to be able to keep a record of users so that we may update them on
any critical changes to the textbook. Please contact Dr. Fialkowski
Revilla if you are considering to adopt the textbook for your course.
About the Contributors | xxxix

Acknowledgements
This Open Educational Resource textbook has been adapted from:

OpenStax Anatomy and Physiology // CC BY 4.0
• Chapter 2 The Human Body
An Introduction to Human Nutrition // CC BY-NC-SA 3.0
• Chapter 1 Basic Concepts in Nutrition

• Chapter 3 Water and Electrolytes
• Chapter 4 Carbohydrates
• Chapter 5 Lipids
• Chapter 6 Protein
• Chapter 8 Energy
• Chapter 12 Nutrition Applications
• Chapter 13 Lifespan Nutrition From Pregnancy to the Toddler
Years
• Chapter 14 Lifespan Nutrition During Childhood and
Adolescence
• Chapter 15 Lifespan Nutrition in Adulthood
• Chapter 17 Food Safety
• Chapter 18 Nutritional Issues
Chapters and sections were borrowed and adapted from the above
existing OER textbooks on human nutrition. Without these
foundational texts, a lot more work would have been required to
complete this project. Mahalo (thank you) to those who shared
before us.
All other content should include the following attribution
statement:
—
xl | Acknowledgements
This work is licensed under a Creative Commons Attribution 4.0
International License. Human Nutrition by the University of Hawai’i
at Mānoa Food Science and Human Nutrition Program. Download
this book for free at: http://pressbooks.oer.hawaii.edu/
humannutrition/
—
This Open Educational Resource textbook was also inspired by:
Kansas State University Human Nutrition | goo.gl/vOAnR // CC
BY 3.0
Edited and Reviewed by
Carolyn Donohoe-Mather – University of Hawai’i at Mānoa, Chapter

reviewer
Cecille Farnum — Ryerson University, Copyeditor
Changqi Leu — San Diego State University, Chapter reviewer
Billy Meinke — University of Hawai’i at Mānoa, Project manager
Paula Parslow — Private, Copyeditor
Trina Robertson — Saddleback College, Chapter reviewer
Allison Tepper — American University, Chapter reviewer
Front Cover Photo
Noa Kekuewa Lincoln / CC BY 4.0
Acknowledgements | xli
Special Thanks to
Bill Chismar – University of Hawai’i at Mānoa, Dean of Outreach

College
The Children’s Healthy Living Summer Institute – University of
Hawai’i at Mānoa
Open Educational Resources
This text is provided to you as an Open Educational Resource (OER)

which you access online. It is designed to give you a comprehensive
introduction to human nutrition at no or very nominal cost. It
contains both written and graphic text material, intra-text links to
other internal material which may aid in understanding topics and
concepts, intra-text links to the appendices and glossary for tables
and definitions of words, and extra-text links to videos and web
material that clarifies and augments topics and concepts.
xlii | Acknowledgements
PART I
CHAPTER 1. BASIC
CONCEPTS IN NUTRITION
Chapter 1. Basic Concepts in

Nutrition | 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
Introduction | 3
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).
4 | Introduction
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. 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
Introduction | 5
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.
6 | Introduction
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
Macronutrie
nts:
Carbohydrat
es, Lipids,
Protein, and
Water
Introduction | 7
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 “Minerals and Their Major Functions” and Table 1.2
“Vitamins and Their Major Functions” 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
8 | Introduction
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,
Calcium
muscle contraction, blood clotting
Phosphorus Bone and teeth health maintenance, acid-base balance
Protein production, nerve transmission, muscle

Magnesium
contraction
Sulfur Protein production
Trace
Iron Carries oxygen, assists in energy production

Protein and DNA production, wound healing, growth,
Zinc
immune system function
Iodine Thyroid hormone production, growth, metabolism
Selenium Antioxidant
Copper Coenzyme, iron metabolism
Manganese Coenzyme
Bone and teeth health maintenance, tooth decay
Fluoride
prevention
Chromium Assists insulin in glucose metabolism
Molybdenum Coenzyme
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
Introduction | 9
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
10 | Introduction
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
Coenzyme, energy metabolism assistance
(B5)
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

Bone and teeth health maintenance, immune system
D
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
Introduction | 11
Necessary for tissue formation, cell reparation, and
Protein hormone and enzyme production. It is essential for
building strong muscles and a healthy immune system.
Provide a ready source of energy for the body and
Carbohydrates provide structural constituents for the formation of
cells.
Provides stored energy for the body, functions as
structural components of cells and also as signaling
Fat molecules for proper cellular communication. It
provides insulation to vital organs and works to
maintain body temperature.
Regulate body processes and promote normal
Vitamins
body-system functions.
Regulate body processes, are necessary for proper
Minerals
cellular function, and comprise body tissue.
Transports essential nutrients to all body parts,
Water transports waste products for disposal, and aids with
body temperature maintenance.
Learning Activities
Technology Note: The second edition of the Human

Nutrition Open Educational Resource (OER) textbook
features interactive learning activities. These activities are
available in the web-based textbook and not available in the
downloadable versions (EPUB, Digital PDF, Print_PDF, or
Open Document).
Learning activities may be used across various mobile

devices, however, for the best user experience it is strongly
12 | Introduction
recommended that users complete these activities using a
desktop or laptop computer and in Google Chrome.
An interactive or media element has been

excluded from this version of the text. You can
view it online here:
http://pressbooks.oer.hawaii.edu/
humannutrition2/?p=46

Introduction | 13
Food Quality
Image by
David De
Veroli on
unsplash.co
m / CC0
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.
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
14 | Food Quality
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?
Food Quality | 15
USDA
https://ww
w.ars.usda.
gov/
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Learning Activities

16 | Food Quality
Open Document).


Food Quality | 17
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
18 | Units of Measure
Volume

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

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
Learning Activities

Units of Measure | 19
Open Document).


20 | Units of Measure
Lifestyles and Nutrition
Image by
John Towner
on
unsplash.co
m / CC0
In addition to nutrition, health is affected by genetics, the

environment, life cycle, and lifestyle. One facet of lifestyle is your
dietary habits. Recall that we discussed briefly how nutrition affects
health. A greater discussion of this will follow in subsequent
chapters in this book, as there is an enormous amount of
information regarding this aspect of lifestyle. Dietary habits include
what a person eats, how much a person eats during a meal, how
frequently meals are consumed, and how often a person eats out.
Other aspects of lifestyle include physical activity level, recreational
drug use, and sleeping patterns, all of which play a role in health and
impact nutrition. Following a healthy lifestyle improves your overall
health.
Lifestyles and Nutrition | 21

Physical Activity
In 2008, the Health and Human Services (HHS) released the Physical
1
Activity Guidelines for Americans . The HHS states that “Being
physically active is one of the most important steps that Americans
of all ages can take to improve their health. The 2008 Physical
Activity Guidelines for Americans provides science-based guidance
to help Americans aged six and older improve their health through
appropriate physical activity.” The guidelines recommend exercise
programs for people in many different stages of their lifecycle. The
HHS reports that there is strong evidence that increased physical
activity decreases the risk of early death, heart disease, stroke,
Type 2 diabetes, high blood pressure, and certain cancers; prevents
weight gain and falls; and improves cognitive function in the elderly.
These guidelines are scheduled for an update in 2018. Also unveiled
recently are the Canadian Physical Activity Guidelines, which are
available at the website of The Canadian Society for Exercise
2
Physiology .
Recreational Drug Use
Recreational drug use, which includes tobacco-smoking, electronic

smoking device use, and alcohol consumption along with narcotic
and other illegal drug use, has a large impact on health. Smoking
1. U.S. Department of Health and Human Services' Office of

Disease Prevention and Health Promotion. Physical
Activity. https://health.gov/paguidelines/
2. Canadian Society for Exercise Physiology.
http://www.csep.ca/english/view.asp?x=804
22 | Lifestyles and Nutrition

cigarettes can cause lung cancer, eleven other types of cancer,
heart disease, and several other disorders or diseases that markedly
decrease quality of life and increase mortality. In the United States,
smoking causes more than four hundred thousand deaths every
single year, which is far more than deaths associated with any other
3
lifestyle component .
Also, according to the Centers for Disease Control and Prevention
(CDC), excessive alcohol intake causes an estimated seventy-five
4
thousand deaths per year . Staying away from excessive alcohol
intake lowers blood pressure, the risk from injury, heart disease,
stroke, liver problems, and some types of cancer. While excessive
alcohol consumption can be linked to poor health, consuming
alcohol in moderation has been found to promote health such as
reducing the risk for heart disease and Type 2 diabetes in some
people. The United States Department of Health and Human
Services (HHS) defines drinking in moderation as no more than one
5
drink a day for women and two drinks a day for men .
Illicit and prescription drug abuse are associated with decreased
health and is a prominent problem in the United States. The health
3. Centers for Disease Control and Prevention (2020, April

28). Tobacco and Mortality. http://www.cdc.gov/
tobacco/data_statistics/fact_sheets/health_effects/
tobacco_related_mortality/Index.htm.
4. Centers for Disease Control and Prevention (2020,
January 3). Underage Drinking. http://www.cdc.gov/
healthyyouth/alcoholdrug/
5. U.S. Department of Health and Human Services and U.S.
Department of Agriculture (2015, December). 2015 – 2020
Dietary Guidelines for Americans. 8th
Edition. https://health.gov/our-work/food-nutrition/
2015-2020-dietary-guidelines/guidelines/

effects of drug abuse can be far-reaching, including the increased
6
risk of stroke, heart disease, cancer, lung disease, and liver disease .
Sleeping Patterns
Inadequate amounts of sleep, or not sleeping well, can also have

remarkable effects on a person’s health. In fact, sleeping can affect
your health just as much as your diet. Scientific studies have shown
that insufficient sleep increases the risk for heart disease, Type 2
diabetes, obesity, and depression. Abnormal breathing during sleep,
a condition called sleep apnea, is also linked to an increased risk for
7
chronic disease .
Personal Choice: The Challenge of Choosing

Foods
There are other factors besides environment and lifestyle that

influence the foods you choose to eat. Different foods affect energy
level, mood, how much is eaten, how long before you eat again, and
if cravings are satisfied. We have talked about some of the physical
effects of food on your body, but there are other effects too.
Food regulates your appetite and how you feel. Multiple studies
6. National Institute on Drug Abuse (2017, March 23). Health

Consequences of Drug Misuse.
https://www.drugabuse.gov/related-topics/health-
consequences-drug-misuse.
7. National Sleep Foundation. Sleep Disorders.
https://sleepfoundation.org/sleep-disorders-problems

have demonstrated that some high fiber foods and high-protein
foods decrease appetite by slowing the digestive process and
prolonging the feeling of being full or satiety. The effects of
individual foods and nutrients on mood are not backed by
consistent scientific evidence, but in general, most studies support
that healthier diets are associated with a decrease in depression and
improved well-being. To date, science has not been able to track the
exact path in the brain that occurs in response to eating a particular
food, but it is quite clear that foods, in general, stimulate emotional
responses in people. Food also has psychological, cultural, and
religious significance, so your personal choices of food affect your
mind, as well as your body. The social implications of food have a
great deal to do with what people eat, as well as how and when.
Special events in individual lives—from birthdays to funerals—are
commemorated with equally special foods. Being aware of these
forces can help people make healthier food choices—and still honor
the traditions and ties they hold dear.
Typically, eating kosher food means a person is Jewish; eating
fish on Fridays during Lent means a person is Catholic; fasting
during the ninth month of the Islamic calendar means a person
is Muslim. On New Year’s Day, Japanese take part in an annual
tradition of Mochitsuki also known as Mochi pounding in hopes
of gaining good fortune over the coming year. Several hundred
miles away in Hawai‘i, people eat poi made from pounded taro root
with great significance in the Hawaiian culture, as it represents
Hāloa, the ancestor of chiefs and kanaka maoli (Native Hawaiians).
National food traditions are carried to other countries when people
immigrate. The local cuisine in Hawai‘i would not be what it is
today without the contributions of Japanese, Chinese, European,
and other immigrant communities.

Factors that Drive Food Choices
Along with these influences, a number of other factors affect the

dietary choices individuals make, including:
• Taste, texture, and appearance. Individuals have a wide range

of tastes which influence their food choices, leading some to
dislike milk and others to hate raw vegetables. Some foods that
are very healthy, such as tofu, may be unappealing at first to
many people. However, creative cooks can adapt healthy foods
to meet most people’s taste.
• Economics. Access to fresh fruits and vegetables may be scant,
particularly for those who live in economically disadvantaged
or remote areas, where cheaper food options are limited to
convenience stores and fast food.
• Early food experiences. People who were not exposed to
different foods as children, or who were forced to swallow
every last bite of overcooked vegetables, may make limited
food choices as adults.
• Habits. It’s common to establish eating routines, which can
work both for and against optimal health. Habitually grabbing a
fast food sandwich for breakfast can seem convenient, but
might not offer substantial nutrition. Yet getting in the habit of
drinking an ample amount of water each day can yield multiple
benefits.
• Culture. The culture in which one grows up affects how one
sees food in daily life and on special occasions.
• Geography. Where a person lives influences food choices. For
instance, people who live in Midwestern US states have less
access to seafood than those living along the coasts.
• Advertising. The media greatly influences food choice by
persuading consumers to eat certain foods.
• Social factors. Any school lunchroom observer can testify to
the impact of peer pressure on eating habits, and this

influence lasts through adulthood. People make food choices
based on how they see others and want others to see them. For
example, individuals who are surrounded by others who
consume fast food are more likely to do the same.
• Health concerns. Some people have significant food allergies,
to peanuts for example, and need to avoid those foods. Others
may have developed health issues which require them to follow
a low salt diet. In addition, people who have never worried
about their weight have a very different approach to eating
than those who have long struggled with excess weight.
• Emotions. There is a wide range in how emotional issues affect
eating habits. When faced with a great deal of stress, some
people tend to overeat, while others find it hard to eat at all.
• Green food/Sustainability choices. Based on a growing
understanding of diet as a public and personal issue, more and
more people are starting to make food choices based on their
environmental impact. Realizing that their food choices help
shape the world, many individuals are opting for a vegetarian
diet, or, if they do eat animal products, striving to find the
most “cruelty-free” options possible. Purchasing local and
organic food products and items grown through sustainable
processes also helps shrink the size of one’s dietary footprint.
People choose a vegetarian diet for various reasons, including

religious doctrines, health concerns, ecological and animal welfare
concerns, or simply because they dislike the taste of meat. There
are different types of vegetarians, but a common theme is that
vegetarians do not eat meat. Four common forms of vegetarianism
are:
1. Lacto-ovo vegetarian. This is the most common form. This

type of vegetarian diet includes the animal foods eggs and
dairy products.
2. Lacto-vegetarian. This type of vegetarian diet includes dairy
products but not eggs.

3. Ovo-vegetarian. This type of vegetarian diet includes eggs but
not dairy products.
4. Vegan. This type of vegetarian diet does not include dairy,
eggs, or any type of animal product or animal by-product.
Learning Activities

Open Document).




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:
1. A diet must be adequate, by providing sufficient amounts of

each essential nutrient, as well as fiber and adequate calories.
2. A balanced diet results when you do not consume one nutrient
at the expense of another, but rather get appropriate amounts
of all nutrients.
3. 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.
4. Moderation means not eating to the extremes, neither too
much nor too little.
5. 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 for generations.
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, 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).
30 | Achieving a Healthy Diet

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.
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 an essential nutrient, excessive intake may
contribute to congestive heart failure and chronic kidney disease
in some people. Remember, everything must be consumed in the
proper amounts.
Moderation
Eat in moderation. Moderation is crucial for optimal health and

survival. Eating nutrient-poor foods 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 significantly
Achieving a Healthy Diet | 31

impact 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.
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 accumulation of
stored body fat and weight gain. In order to lose body fat, 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.
Variety
Variety involves eating different foods from all the food groups.
Eating a varied diet helps to ensure that you consume and absorb
adequate amounts of all essential nutrients required for health. 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.
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 promote lasting health benefits.
32 | Achieving a Healthy Diet

Learning Activities

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Achieving a Healthy Diet | 33

Research and the Scientific
Method
ask more
questions
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https://www
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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.
34 | Research and 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.
Hypothesis. In 1813, Swiss physician Jean-Francois Coindet
hypothesized that the seaweed contained iodine, and that iodine
1
could be used instead of seaweed to treat his patients .
1. Zimmerman, M.B. (2008). Research on Iodine Deficiency

and Goiter in the 19th and Early 20th Centuries. Journal
Research and the Scientific Method | 35

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,
2
Ohio.
of Nutrition, 138(11), 2060–63. http://jn.nutrition.org/

content/138/11/2060.full
2. Carpenter, K.J. (2005). David Marine and the Problem of
Goiter. Journal of Nutrition, 135(4),
675–80. http://jn.nutrition.org/content/135/4/
675.full?sid=d06fdd35-566f -42a2-a3fd- ef be0736b7ba
36 | Research and the Scientific Method

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
3
designing nutritional guidelines . An evidence-based approach to
4
nutrition includes :
• 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
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.
http://jandonline.org/article/S0002-8223(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.
https://www.ncbi.nlm.nih.gov/pubmed/10806978

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. Full text versions
of the DRI publications are available in pdf format at
https://www.nap.edu/, along with many other free publications.
Learning Activities

Open Document).






Types of Scientific Studies
There are various types of scientific studies on humans that can

be used to provide supporting evidence for a particular hypothesis.
These include epidemiological studies, interventional clinical trials,
and randomized clinical trials. Valuable nutrition knowledge also is
obtained from animal studies and cellular and molecular biology
research.
Table 1.4 Types of Scientific Studies
Types of Scientific Studies | 41

Type Description Example Notes
Observational
study of Diets with a high
populations consumption of Does not
around the saturated fat are determine
Epidemiological
world and the associated with an cause-and-effect
impact of increased risk of relationships.
nutrition on heart attacks.
health.
Testing the effect

of different diets
on blood pressure.
Scientific
One group
investigations If done correctly,
consumes an
where a it does
Intervention American diet,
variable is determine
Clinical Trials group 2 eats a diet
changed cause-and-effect
rich in fruits and
between relationships.
vegetables, and
groups.
group 3 eats a
combination of
groups 1 and 2.
Participants Testing the effect
are assigned of calcium
by chance to supplements on
separate women with
groups that osteoporosis.
compare Participants are
different given a pill daily of Considered the
Randomized treatments. a placebo or “gold” standard
Clinical Trials Neither the calcium for scientific
researchers supplement. studies.
nor the Neither the
participants participant nor
can choose the researcher
which group a know what group
participant is the participant is
assigned. in.
Testing the effects Less expensive

of a new blood than human
Studies are
pressure drug on trials. Study is
Animal and conducted on
guinea pigs or on not on whole
Cellular Biology animals or on
the lipid humans so it
cells.
membrane of a may be not
cell. applicable.
42 | Types of Scientific Studies

Nutrition Assessment
Nutritional assessment is the interpretation of anthropometric,

biochemical (laboratory), clinical and dietary data to determine
whether a person or groups of people are well nourished or
malnourished (overnourished or undernourished).
Nutritional assessment can be done using the ABCD methods.
These refer to the following:
• A. Anthropometry
• B. Biochemical methods
• C. Clinical methods
• D. Dietary methods
Anthropometry methods of assessing nutritional

status
The word anthropometry comes from two words: Anthropo means

‘human’ and metry means ‘measurement’. The different
measurements taken to assess growth and body composition are
presented below.
To assess growth, several different measurements including
length, height, weight, head circumference, mid-arm
circumference, skin-fold thickness, head/chest ratio, and hip/waist
ratio can be used. Height and weight measurements are essential in
children to evaluate physical growth. As an additional resource, the
NHANES Anthropometry Procedures Manual (revised January 2004)
can be viewed here https://www.cdc.gov/nchs/data/nhanes/
nhanes_03_04/BM.pdf
Figure 1.3 Measuring Height

(Source:
UNICEF,
1986, How to
weigh and
measure
children:
assessing the
nutrition
status of
young
children)
Biochemical methods of assessing nutritional

status
Biochemical or laboratory methods of assessment include

measuring a nutrient or its metabolite in the blood, feces, urine or
other tissues that have a relationship with the nutrient. An example
of this method would be to take blood samples to measure levels
of glucose in the body. This method is useful for determining if an
individual has diabetes.
Figure 1.4 Measuring Blood Glucose Levels

Image by
TesaPhotogr
aphy / CC0
Clinical methods of assessing nutritional status
In addition to the anthropometric assessments, you can also assess

clinical signs and symptoms that might indicate potential specific
nutrient deficiency. Special attention are given to organs such as
skin, eyes, tongue, ears, mouth, hair, nails, and gums. Clinical
methods of assessing nutritional status involve checking signs of
deficiency at specific places on the body or asking the patient
whether they have any symptoms that might suggest nutrient
deficiency.
Dietary methods of assessing nutritional status
Dietary methods of assessment include looking at past or current

intakes of nutrients from food by individuals or a group to
determine their nutritional status. There are several methods used
to do this:

24 hour recall
A trained professional asks the subject to recall all food and drink
consumed in the previous 24 hours. This is a quick and easy method.
However, it is dependent upon the subject’s short-term memory
and may not be very accurate.
Food frequency questionnaire
The subject is given a list of foods and asked to indicate intake per
day, per week, and per month. This method is inexpensive and easy
to administer. It is more accurate than the 24 hour recall.
Food Diary
Food intake is recorded by the subject at the time of eating. This

method is reliable but difficult to maintain. Also known as a food
journal or food record.
Observed food consumption
This method requires food to be weighed and exactly calculated. It

is very accurate but rarely used because it is time-consuming and
expensive.
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 some can be biased. Therefore, it is
important to know where a scientific study was conducted and who
provided the funding, as this can have an impact on the scientific
conclusions being made. For example, an air quality study paid for
by a tobacco company diminishes its value in the minds of readers
as well as a red meat study performed at a laboratory funded by a
national beef association.
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 of 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.
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. 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 also may delve into the field of nutritional genetics
and download your gene expression profiles to a database that
analyzes your genes against millions of others.
Nutrition and the Media
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.
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 Nutrition.
Question studies that come from less trustworthy sources
(such as non peer-reviewed journals or websites) or that are
not formally 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 adds to credibility.
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. Are names and credentials disclosed?
3. Is an editorial board identified?
4. Does the site contain links to other credible informational
websites?
5. 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?
6. How often is the website updated?
7. Are you being sold something at this website?
8. Does the website charge a fee?
For more information, visit http://www.csuchico.edu/lins/

handouts/eval_websites.pdf
Trustworthy Sources
Now let’s consider some reputable organizations and websites from

which you can usually obtain valid nutrition information.
Organizations Active in Nutrition Policy and

Research
Authoritative nutritional news will be based upon solid scientific

evidence, supported by multiple studies, and published in peer-
reviewed journals. Whatever the source of your nutritional news,
remember to apply the criteria outlined above to help ensure the
validity of the information presented. Below are some examples of
websites which can be considered credible sources for nutritional
news.
• US Department of Agriculture Food and Nutrition Information

Center. The USDA site http://fnic.nal.usda.gov has more than
2,500 links to information about diet, nutrition, diet and
disease, weight and obesity, food-safety and food-labeling,
packaging, dietary supplements and consumer questions.
Using this interactive site, you can find tips and resources on
how to eat a healthy diet, nutritional information, and a food
planner.
• The Academy of Nutrition and Dietetics (AND). The AND
promotes scientific, evidenced-based, research-supported
food and nutrition related information on its website,
http://www.eatright.org. It is focused on informing the public
about recent scientific discoveries and studies, weight-loss
concerns, food safety topics, nutrition issues, and disease
prevention.
• Department of Health and Human Services (HHS). The HHS
website, HealthFinder.gov, 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 information on daily health issues in general.
• Centers for Disease Control and Prevention (CDC). The
Centers for Disease Control and Prevention
(http://www.cdc.gov) distributes an online newsletter called
CDC Vital Signs which provides up-to-date public health
information and data regarding food, nutrition, cholesterol,
high blood pressure, obesity, teenage drinking, and tobacco

usage.
Learning Activities

Open Document).



PART II
CHAPTER 2. THE HUMAN
BODY
Chapter 2. The Human Body | 53

Introduction
I ola no ke kino i ka māʻona o ka ʻōpū
The body enjoys health when the stomach is full
Image by
Henrique
Felix on
unsplash.co
m / CC0
Learning Objectives
Introduction | 55
• 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)
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
56 | Introduction
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
1
bowel disease, and cancer.
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
2
food.
The Japanese also have traditional fermented foods such as natto.
Natto is made from fermented soybeans and has many health
1. Brown A, Valiere A. (2004). The Medicinal Uses of Poi.

Nutrition in Clinical Care, 7(2), 69-74.
https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC1482315/
2. Park K, Jeong J, et al. (2014). Health Benefits of Kimchi.
Journal of Medicinal Food, 17(1), 6-20.
Introduction | 57
benefits as a probiotic. Along with the beneficial components, natto
is very nutrient-dense containing carbohydrates, fats, protein, fiber,
3
vitamins and minerals. Other common foods we ferment in our diet
include miso, sauerkraut, kombucha, and tempeh.
Figure 2.1 Components of Organ Systems in the Human Body
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. http://www.sciencedirect.com/science/
article/pii/S0924224415300571
58 | Introduction
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
Introduction | 59
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.”
Learning Activities

Open Document).


60 | Introduction
Introduction | 61
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
62 | Basic Biology, Anatomy, and
Physiology
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.
Although we defined the cell as the “most basic” unit of life,
it is structurally and functionally complex (Figure 2.2 “The Cell
Structure”). 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 2.2 The Cell Structure
Basic Biology, Anatomy, and Physiology | 63

Figure 2.2
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 (see Figure 2.3 “Organization of Life”.
• 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
64 | Basic Biology, Anatomy, and Physiology

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 2.1 “The Eleven Organ Systems in
the Human Body and Their Major Functions”).
• An organism is the complete living system capable of
conducting all of life’s biological processes.
Figure 2.3 Organization of Life

“Organizatio
n Levels of
Human
Body”
by Laia
Martinez /
CC BY-SA 4.0

Table 2.1 The Eleven Organ Systems in the Human Body and Their
Major Functions
Organ System Organ Components Major Function

heart, blood/lymph
Transport nutrients and waste
Cardiovascular vessels, blood,
products
lymph
mouth, esophagus,
Digestive Digestion and absorption
stomach, intestines
all glands (thyroid,
Endocrine Produce and release hormones
ovaries, pancreas)
A one-way system of vessels that
tonsils, adenoids,
Lymphatic transport lymph throughout the
spleen and thymus
body
white blood cells,
Immune lymphatic tissue, Defend against foreign invaders
marrow
skin, nails, hair, Protective, body temperature
Integumentary
sweat glands regulation
skeletal, smooth,
Muscular Body movement
and cardiac muscle
brain, spinal cord,
Nervous Interprets and responds to stimuli
nerves
Reproduction and sexual
Reproductive gonads, genitals
characteristics
lungs, nose, mouth,

Respiratory Gas exchange
throat, trachea
bones, tendons,
Skeletal Structure and support
ligaments, joints
Urinary, kidneys, bladder,
Waste excretion, water balance
Excretory ureters
66 | Basic Biology, Anatomy, and Physiology

Learning Activities

Open Document).



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 2.4 “The
Human Digestive System”) 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 2.4 Digestion Breakdown of Macronutrients
68 | The Digestive System

3 molecules of Glucose, Lipids becomes 1 molecule of fatty acids and
and one molecule of glycerol, and Proteins become 3 molecultes
of Amino Acids” class=”alignnone wp-image-77″ width=”438″
height=”234″>
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.
The Digestive System | 69

Everyday Connection
Image by
Gabriel Lee
/ CC
BY-NC-SA
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
1
and reduce the symptoms of lactose intolerance.
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.
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 http://www.kefir.net/
recipes.htm.
Kefir, a dairy product fermented with probiotic bacteria,
can make a pleasant tasting milkshake.
Figure 2.5 The Human Digestive System
1. Farnworth ER. (2008). The Evidence to Support Health

Claims for Probiotics. Journal of Nutrition, 138(6),
1250S–4S. http://jn.nutrition.org/content/138/6/
1250S.long

Image by
Allison
Calabrese /
CC BY 4.0
From the Mouth to the Stomach
There are four steps in the digestion process (Figure 2.5 “The
Human Digestive System”). 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.
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
3.6 “Peristalsis in the Esophagus”). 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.
Figure 2.6 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 (.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 2.7 “Segmentation”). 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.
Figure 2.7 Segmentation
“Segmentatio
n” 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 2.8 “Structure of the Small Intestine”). 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 2.8 Structure of the Small Intestine
“Histology
Small
Intestines” by
OpenStax
College / CC
BY 3.0

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 (see Figure 2.9 “The
Absorption of Nutrients”).
Figure 2.9 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.
Learning Activities

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The Cardiovascular System
Figure 2.10 The Cardiovascular system
82 | The Cardiovascular System

“Simplified
diagram of
the human
Circulatory
system in
anterior
view” by
Mariana
Ruiz / Public
Domain
The Cardiovascular System | 83

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 2.12 “Cardiovascular Transportation
of Nutrients”). This system consists of the heart, blood, and blood
vessels. 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.
Figure 2.11 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.
Figure 2.12 Cardiovascular Transportation of Nutrients

The
cardiovascul
ar 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.”
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?
Figure 2.13 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
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.
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 2.2 “Blood Tests”
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 2.2 Blood Tests

Substance Measured Indicates
Red-blood-cell count Oxygen-carrying capacity

Hematocrit (red-blood-cell
Anemia risk
volume)
White-blood-cell count Presence of infection
Bleeding disorders, atherosclerosis
Platelet count
risk
Metabolic, kidney, respiratory

pH
abnormalities
Liver, kidney, and Crohn’s disease,
Albumin
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,
Many illnesses (kidney, metabolic, etc.)
magnesium, potassium)
Cholesterol Cardiovascular disease risk
Triglycerides Cardiovascular disease risk
Glucose Diabetes risk
Many illnesses (diabetes, reproductive
Hormones
abnormalities)
1
National Heart Lung and Blood Institute. Types of Blood Tests.
1. National Heart Lung and Blood Institute (2012, January

6). Blood Tests. http://www.nhlbi.nih.gov/health/health-
topics/topics/bdt/types.html

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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. 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 2.14 The Central Nervous System
94 | 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
Central Nervous System | 95

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
1
Alzheimer’s disease.
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
1. Gu Y, Nieves JW, et al. (2010). Food Combination and

Alzheimer Disease Risk: A Protective Diet. Archives of
Neurology, 67(6), 699–706.

juice every day for twelve weeks had improved learning and
memorization skills in comparison to other subjects given a placebo
2
drink.
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.
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2. Krikorian R, Shidler MD, et al. (2010). Blueberry

Supplementation Improves Memory in Older Adults.
Journal of Agricultural and Food Chemistry, 58(7).
Central Nervous System | 97



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 2.15 Major Respiratory Structures
The Respiratory System | 99

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
100 | The Respiratory System

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 2.16
“Respiratory Zone”), which then leads to an alveolar duct, opening
into a cluster of alveoli.
Figure 2.16 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 2.17 Location of Respiratory System
“Human
Respiratory
System” by
United
States
National
Institute of
Health:
National
Heart, Lung
and Blood
Institute /
Public
Domain
Figure 2.17 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. CO2 is carbon dioxide,
and O2 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.

Gross Anatomy of the Lungs
The lungs are pyramid-shaped, paired organs that are connected

to the trachea by the right and left bronchi; below the lungs is the
diaphragm, a flat, dome-shaped muscle located at the base of the
lungs and thoracic cavity.
Figure 2.18 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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The Endocrine System
Figure 2.19 The Endocrine System

“Major
Endocrine
Glands” by
National
Cancer
Institute /
Public
Domain
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
106 | The Endocrine System

in the endocrine system are the pituitary, thyroid, parathyroid,
adrenals, thymus, pineal, pancreas, ovaries, and testes. 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.
https://www.cdc.gov/diabetes/statistics/slides/
maps_diabetesobesity_trends.pdf
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.
The Endocrine System | 107

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 https://www.cdc.gov/diabetes/. It
provides information on education resources, projects, and
programs, and spotlights news on diabetes. For helpful
information on obesity, visit https://www.cdc.gov/
obesity/. The CDC also has workplace web-based
resources with the mission of designing work sites that
prevent obesity. See https://www.cdc.gov/
workplacehealthpromotion/index.html or more details.
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108 | The Endocrine System



The Endocrine System | 109

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. For
110 | The Urinary System

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 2.20 Urine Color
The Urinary System | 111

“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.
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 2.21 “Urinary System Location”).
Figure 2.21 Urinary System Location

“Illu Urinary
System” by
Thstehle /
Public
Domain
Figure 2.22 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.
Figure 2.23 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 Ca++. The
kidney hormone EPO stimulates erythrocyte development and
promotes adequate O2 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:
Na+, Ca++, and K+. 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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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 (see
Figure 2.24 “The Muscular System in the Human Body”). 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 2.24 The Muscular System in the Human Body
The Muscular System | 117

“Muscle
Types” by
BruceBlaus /
CC BY-SA 4.0
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118 | The Muscular System

The Muscular System | 119

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. 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
120 | The Skeletal System

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.
Figure 2.25 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.
The Skeletal System | 121

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 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 2.26 “The Arrangement of Bone Tissues”). 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 2.27 “Cortical (Compact) Bone”).
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 2.26 The Arrangement of Bone Tissues
Image
by Gtirouflet
/ CC BY-SA
3.0
The two basic tissue types of bones are trabecular and cortical. This
photo shows normal (left) and degraded (right) trabecular (spongy)
bone.
Figure 2.27 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 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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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
The Immune System | 129

longer than three months significantly reduces the incidence and
1
severity of diarrhea and respiratory illnesses.
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. https://www.ncbi.nlm.nih.gov/pubmed/
17545379
130 | The Immune System

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The Immune System | 131

132 | The Immune System

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. 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.
Indicators of Health: Body Mass

Index, Body Fat Content, and Fat
Figure 2.28 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
134 | Indicators of Health: Body Mass Index, Body Fat Content, and Fat
Distribution
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.
BMI = [weight (lb) x 703] ÷ height (in)2
or
BMI = [weight (kg)] ÷ height (m)2
More Ways to Calculate
The National Heart, Lung, and Blood Institute and the CDC have
automatic BMI calculators on their websites:
• https://www.nhlbisupport.com/bmi/
• https://www.cdc.gov/healthyweight/assessing/bmi/
adult_bmi/english_bmi_calculator/bmi_calculator.html
To see how your BMI indicates the weight category you are in, see
Table 2.3 “BMI Categories”.
Table 2.3 BMI Categories
Categories BMI
Underweight < 18.5

Healthy or Normal weight 18.5–24.9
Overweight 25–29.9
Obese > 30.0
Indicators of Health: Body Mass Index, Body Fat Content, and Fat
Distribution | 135
Source: National Heart, Lung, and Blood Institute. Accessed
November 4, 2012. https://www.nhlbi.nih.gov.
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.
Distribution
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.
Figure 2.29 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

Distribution | 137
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 2.30 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
Distribution
can be accurately estimated.
Figure 2.31 Dual-Energy X-ray Absorptiometry (DEXA)

“A
Dual-energy
X-ray
absorptiomet
ry (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
Distribution | 139
and women with a waist circumference greater than 35 inches are
predicted to face greater health risks.
Figure 2.32 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. 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
Distribution
participants from fifty-two countries concluded that the waist-to-
hip ratio is highly correlated with heart attack risk worldwide and is
1
a better predictor of heart attacks than BMI. . 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.
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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. https://pubmed.ncbi.nlm.nih.gov/16271645/
Distribution | 141

Distribution
PART III
CHAPTER 3. WATER AND
ELECTROLYTES
Chapter 3. Water and

Electrolytes | 143
Introduction
Ola i ka wai a ka ‘ōpua
There is life in the water from the clouds
Image by
Cassie
Matias on
unsplash.co
m / CC0
Introduction | 145
Image by Cassie Matias on unsplash.com / CC0
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
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
146 | Introduction
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
1
percent of Americans consume sugary drinks daily.
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
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.
http://www.cdc.gov/nchs/data/databriefs/db71.htm.
Published August 2011. Accessed September 22, 2017.
Introduction | 147
the sodium lost in sweat and promotes fluid uptake in the small
intestine, improving hydration.
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.
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148 | Introduction
Introduction | 149
Overview of Fluid and
Electrolyte Balance
Water is made up of 2 hydrogen atoms and 1 oxygen atom (Figure 3.1

“The Water Molecule”). 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
1
significantly decreased risk for developing colon cancer.
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.
150 | Overview of Fluid and
Electrolyte Balance
Figure 3.1 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
http://cebp.aacrjournals.org/content/5/7/495.long.
Accessed September 22, 2017.
Overview of Fluid and Electrolyte Balance | 151

and negatively charged electrolytes are called anions. For example,
in water sodium chloride (the chemical name for table salt)
dissociates into sodium cations (Na+) and chloride anions (Cl−).
Solutes refers to all dissolved substances in a fluid, which may
be charged, such as sodium (Na+), 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 3.2
“Distribution of Body Water”). 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 3.2 Distribution of Body Water
Image by
Allison
Calabrese /
CC BY 4.0
Osmoregulation
One of the essential homeostatic functions of the body is to

maintain fluid balance and the differences in solute composition
152 | Overview of Fluid and Electrolyte Balance

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 3.3 “Osmoregulation”). 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 3.3 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.
154 | Overview of Fluid and Electrolyte Balance

Learning Activities

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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.
Image by
NASA on
unsplash.co
m / CC0
156 | Water’s Importance to Vitality

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
Water’s Importance to Vitality | 157

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.
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 3.4 “Thermoregulatory Center”).
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.
Figure 3.4 Thermoregulatory Center

Thermoregul
ation is the
ability of an
organism to
maintain
body
temperature
despite
changing
environment
al
temperatures
.
Learning Activities

Open Document).




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 3.5 Daily Fluid Loss and Gain
162 | Regulation of Water Balance

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 ”
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> 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
1
(15.6 cups) and at 2.7 liters (11 cups) for adult females. These intakes
1. Institute of Medicine Panel on Dietary Reference Intakes
Regulation of Water Balance | 163

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 3.1 “Water Content in Foods” for the range of
water contents for selected food items. Beverages includes water,
tea, coffee, sodas, and juices.
Table 3.1 Water Content in Foods
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. http://www.nap.edu/
openbook.php?record_id=10925&page=73. Accessed
September 22, 2017.

Percentage Food Item
Nonfat milk, cantaloupe, strawberries, watermelon, lettuce,

90–99
cabbage, celery, spinach, squash
Fruit juice, yogurt, apples, grapes, oranges, carrots,
80–89
broccoli, pears, pineapple
Bananas, avocados, cottage cheese, ricotta cheese, baked
70–79
potato, 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,

1–9
peanut butter
0 Oils, sugars
Source: National Nutrient Database for Standard Reference, Release

23. US Department of Agriculture, Agricultural Research Service.
http://www.ars.usda.gov/ba/bhnrc/ndl. 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.
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 3.6 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 3.7 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.
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.

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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
172 | Electrolytes Important for Fluid

Balance
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.
Figure 3.8 The Sodium-Potassium Pump
Electrolytes Important for Fluid Balance | 173

The
sodium-pota
ssium pump
is the
primary
mechanism
for cells to
maintain
water
balance
between
themselves
and their
surrounding
environment
.
Learning Activities

Open Document).

174 | Electrolytes Important for Fluid Balance

Electrolytes Important for Fluid Balance | 175

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).
176 | Sodium
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)
Sodium | 177
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
1
ample water.
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 “Dietary
Reference Intakes for Sodium”). Table salt is approximately 40
percent sodium and 60 percent chloride. As a reference point, only
⅔ teaspoon of salt is needed in 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
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. http://www.ncbi.nlm.nih.gov/
pubmed/9303999. Accessed September 22, 2017.
178 | Sodium
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 3.2 Dietary Reference Intakes for Sodium
Sodium | 179
Adequate Tolerable Upper Intake Level
Age Group
Intake(mg/day) (mg/day)
Infants (0–6
120 ND
months)
Infants (6–12
370 ND
months)
Children (1–3
1,000 1,500
years)
Children (4–8
1,200 1,900
years)
Children (9–13
1,500 2,200
years)
Adolescents (14–18
1,500 2,300
years)
Adults (19–50
1,500 2,300
years)
Adults (50–70
1,300 2,300
years)
Adults (> 70 years) 1,200 2,300
ND = not
determined
Source: Dietary Reference Intakes: Water, Potassium, Sodium,

Chloride, and Sulfate. Institute of Medicine. http://www.iom.edu/
Reports/2004/Dietary-Reference-Intakes-Water-Potassium-
Sodium-Chloride-and-Sulfate.aspx. Updated February 11, 2004.
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
180 | Sodium
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 “Sodium Contents of Selected Foods”.
Figure 3.9 Dietary Sources of Sodium
“Food Eat
Salt” by
Clker-Free-V
ector-Images
/ Pixabay
License
Table 3.3 Sodium Contents of Selected Foods
Sodium | 181
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
182 | Sodium
Sodium on the Nutrition Facts Panel
Figure 3.10 Nutrition Label

Sodium
levels in
milligrams is
a required
listing on a
Nutrition
Facts label.
Sodium | 183
The Nutrition Facts panel displays the amount of sodium (in
milligrams) per serving of the food in question (Figure 3.10
“Nutrition Label” ). 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 3.4 “Food Packaging Claims
Regarding Sodium”).
Table 3.4 Food Packaging Claims Regarding Sodium
Claim Meaning
Sodium is reduced by at
“Light in Sodium” or “Low in Sodium”
least 50 percent
No salt added during
“No Salt Added” or “Unsalted” preparation and
processing*
50 percent less sodium
“Lightly Salted” than that added to similar
food
Contains less than 5 mg
“Sodium Free” or “Salt Free”
sodium per serving
“Very Low Salt”
sodium per serving
“Low Salt”
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.

http://www.fda.gov/Food/
GuidanceComplianceRegulatoryInformation/
GuidanceDocuments/FoodLabelingNutrition/FoodLabelingGuide/
ucm064911.htm. Updated October 2009. Accessed October 2, 2011.
184 | Sodium
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 3.5 “Salt Substitutes” displays the
sodium and potassium amounts in some salt substitutes.
Table 3.5 Salt Substitutes
Sodium | 185
Serving Sodium Potassium
Product
Size (mg) (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
1 tsp. 600 0
Seasoning
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.
http://www.uhs.wisc.edu/health-topics/nutrition-fitness-and-
heart-health/documents/Sodium.pdf. Updated March 2011.
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 3.6 “Salt Alternatives” for an AHA list of alternative food
seasonings.
Table 3.6 Salt Alternatives
186 | Sodium
Seasoning Foods
Lean ground meats, stews, tomatoes, peaches, applesauce,

Allspice
cranberry sauce, gravies, lean meat
Almond
Puddings, fruits
extract
Caraway Lean meats, stews, soups, salads, breads, cabbage,
seeds asparagus, noodles
Chives Salads, sauces, soups, lean-meat dishes, vegetables
Cider
Salads, vegetables, sauces
vinegar
Cinnamon Fruits, breads, pie crusts
Curry Lean meats (especially lamb), veal, chicken, fish, tomatoes,
powder tomato soup, mayonnaise,
fish sauces, soups, tomatoes, cabbages, carrots,
Dill cauliflower, green beans, cucumbers, potatoes, salads,
macaroni, lamb
Garlic (not Lean meats, fish, soups, salads, vegetables, tomatoes,
garlic salt) potatoes
Ginger Chicken, fruits

Lemon
Lean meats, fish, poultry, salads, vegetables
juice
Hot breads, apples, fruit salads, carrots, cauliflower,
Mace
squash, potatoes, veal, lamb
lean ground meats, lean meats, chicken, fish, salads,
Mustard
asparagus, broccoli, Brussels sprouts, cabbage,
(dry)
mayonnaise, sauces
Fruits, pie crust, lemonade, potatoes, chicken, fish, lean
Nutmeg
meatloaf, toast, veal, pudding
Onion
Lean meats, stews, vegetables, salads, soups
powder
Paprika Lean meats, fish, soups, salads, sauces, vegetables

Parsley Lean meats, fish, soups, salads, sauces, vegetables
Peppermint
Puddings, fruits
extract
Pimiento Salads, vegetables, casserole dishes
Chicken, veal, lean meatloaf, lean beef, lean pork, sauces,

Rosemary
stuffings, potatoes, peas, lima beans
Sodium | 187
Lean meats, stews, biscuits, tomatoes, green beans, fish,
Sage
lima beans, onions, lean pork
Salads, lean pork, lean ground meats, soups, green beans,

Savory
squash, tomatoes, lima beans, peas
Lean meats (especially veal and lean pork), sauces, soups,
Thyme
onions, peas, tomatoes, salads
Turmeric Lean meats, fish, sauces, rice
Source: Shaking the Salt Habit. American Heart Association.

http://www.heart.org/HEARTORG/Conditions/
HighBloodPressure/PreventionTreatmentofHighBloodPressure/
Shaking-the-Salt-Habit_UCM_303241_Article.jsp. Updated June 6,
2012. Accessed September 22, 2017.
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188 | Sodium
Sodium | 189
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.
190 | Chloride
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 3.7 “Adequate Intakes for Chloride”.
Table 3.7 Adequate Intakes for Chloride
Chloride | 191
Age Group mg/day
Infants (0–6 months) 180

Children (1–3 years) 1,500

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. http://www.iom.edu/
Reports/2004/Dietary-Reference-Intakes-Water-Potassium-
Sodium-Chloride-and-Sulfate.aspx. Updated February 11, 2004.
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
192 | Chloride
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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Chloride | 193
194 | Chloride
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 | 195
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 3.8
“Adequate Intakes for Potassium”.
Table 3.8 Adequate Intakes for Potassium
196 | Potassium
Age Group mg/day


Adolescents (14–18 years) 4,700
Adults (> 19 years) 4,700
Dietary Reference Intakes: Water, Potassium, Sodium, Chloride, and

Sulfate. Institute of Medicine. http://www.iom.edu/Reports/2004/
Dietary-Reference-Intakes-Water-Potassium-Sodium-Chloride-
and-Sulfate.aspx. Updated February 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
Potassium | 197
foods. Fresh and frozen foods are better sources of potassium than
canned.
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198 | Potassium
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
Consequences of Deficiency or
Excess | 199
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
200 | Consequences of Deficiency or Excess

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
1
pressure of 130/80 mm Hg or greater.
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%2fwww.acc.org%2flatest-in-
cardiology%2farticles%2f2017%2f11%2f08%2f11%2f47%2fmon-5pm-
bp-guideline-aha-2017
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
2
percent of Americans were hypertensive. The percentage of people
with hypertension increases to over 60 percent in people over the
age of sixty.
1.
2. Centers for Disease Control and Prevention.
“FastStats—Hypertension.” Accessed October 2, 2011.
http://www.cdc.gov/nchs/fastats/hyprtens.htm.
Consequences of Deficiency or Excess | 201

Figure 3.11 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
34
then went through further analyses.
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
5
higher cardiovascular mortality and all-causes mortality.
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,
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. http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC1834069/. 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.
http://www.ncbi.nlm.nih.gov/pubmed/8634612.
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.
https://www.ncbi.nlm.nih.gov/pubmed/21747015.

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
6
lower than participants with hypertension on the control diet.
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
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.

product development, food reformulation), and information/
7
education strategies for the public and professionals.”
Try for Yourself
The National Heart, Lung, and Blood Institute has

prepared an informative fact sheet on the DASH diet:
http://www.nhlbi.nih.gov/health/public/heart/hbp/
dash/new_dash.pdf.
Use the food-group charts to help design a daily menu that
follows the DASH eating plan.
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. http://www.nap.edu/
openbook.php?record_id=12818&page=
19#p2001bcf59960019001. Accessed September 22, 2017.

“Your
Guide to
Lowering
Blood
Pressure”.
US
Departmen
t 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
8
cardiovascular mortality.”
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8. Salt and Health. The Salt Institute.

http://www.saltinstitute.org/Issues-in-focus/Food-
salt-health. Updated 2011. Accessed October 2, 2011.




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 3.9 “Calories
in Various Beverages”.
Table 3.9 Calories in Various Beverages
Water Concerns | 209

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
1
drinks, energy drinks, fruit drinks, and bottled water.
As in the past, carbonated soft drinks remained the largest
category of consumed beverages. In recent decades total caloric
1. US Liquid Refreshment Beverage Market Increased by

1.2% in 2010, Beverage Marketing Corporation Reports.
Beverage Marketing Corporation.
http://www.beveragemarketing.com/?section=pressrel
eases. Published 2010. Accessed March 17, 2011.
210 | Water Concerns

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
2
obtain 10 percent of their total energy intake from soft drinks.
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 3.10
“Recommendations of the Beverage Panel”). In 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
3
of these factors contribute to increased energy intake and obesity.
2. Beverage Intake in the United States. The Beverage

Panel, University of North Carolina, Chapel Hill.
http://www.cpc.unc.edu/projects/beverage. Accessed
October 2, 2011. (See Figure 6.8 "Percentage of Daily
Caloric Intake from Beverage Groups".)
3. US Liquid Refreshment Beverage Market Increased by
1.2% in 2010, Beverage Marketing Corporation
Reports.Beverage Marketing Corporation.

The Beverage Panel recommends an even lower intake of calories
from beverages than IOM—10 percent or less of total caloric intake.
Table 3.10 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
≤1
drinks
≤ 1, less if trying to lose

Calorie-rich beverages without nutrients
weight
*One serving is eight ounces.
Source: Beverage Panel Recommendations and Analysis. University

of North Carolina, Chapel Hill. US Beverage Guidance Council.
http://www.cpc.unc.edu/projects/nutrans/policy/beverage/us-
beverage-panel. 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
http://www.beveragemarketing.com/?section=pressrel
eases. Accessed March 17, 2011.

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 3.12
“Deadly Water-borne Illnesses In United States”). In fact, the
treatment of drinking water is touted as one of the top public-
health achievements of the last century.
Figure 3.12 Deadly Water-borne Illnesses In United States

Deadly
water-borne
illnesses
decreased to
almost
nonexistent
levels in the
United
States after
the
implementat
ion of water
disinfection
methods.

Source: Image credit Robert Tauxe.
Drinking Water Week. Centers for Disease Control and Prevention.
http://www.cdc.gov/features/drinkingwater/graph.html. 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.
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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
216 | Popular Beverage Choices

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
3.11 “Caffeine Content in Various Beverages and Foods” 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 3.11 Caffeine Content in Various Beverages and Foods
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
Popular Beverage Choices | 217

Source: Caffeine.MedicineNet.com. http://www.medicinenet.com/
caffeine/article.htm. 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.
Photo by
Jeremy
Ricketts on
unsplash.co
m / 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
1
consumption reduces the risk of Type 2 diabetes. The risk
1. van Dam R M, Hu FB. (2005). Coffee Consumption and

Risk of Type 2 Diabetes: A Systematic Review. Journal of

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
2
who consumed more than 3 cups of coffee daily.
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
3
Parkinson’s disease in both men and women. This review also took
into consideration caffeine obtained from dietary sources other
the American Medical Association, 294(1), 97–104.

http://jamanetwork.com/journals/jama/article-
abstract/201177. 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.
http://jamanetwork.com/journals/jama/fullarticle/
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.

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
4
Alzheimer’s disease.
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
5
increases the risk for cardiovascular disease.
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. http://www.ncbi.nlm.nih.gov/pubmed/
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.

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.
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.

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PART IV
CHAPTER 4.
CARBOHYDRATES
Chapter 4. Carbohydrates | 227

Introduction
E ʻai i ka mea i loaʻa
What you have, eat
Two
Breadfruit by
Michael
Coghlan /
CC BY-SA 2.0
Learning Objectives
Introduction | 229
• 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
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
1
of these fiber rich carbohydrate foods.
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
1. Fujita R, Braun KL, Hughes CK. (2004). The traditional

Hawaiian diet: a review of the literature. Pacific Health
Dialogue, 11(2). http://pacifichealthdialog.org.fj/
Volume2011/no2/
PHD1120220p2162022120Yamada20orig.pdf. Accessed
October 19, 2017.
230 | Introduction
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 4.1 Carbohydrate Classification Scheme
Carbohydrat
es are broken
down into
the
subgroups
simple and
complex
carbohydrate
s. These
subgroups
are further
categorized
into mono-,
di-, and
polysacchari
des.
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 C6H12O6. 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
Introduction | 231
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 4.2 “Structures of the Three Most Common
Monosaccharides: Glucose, Galactose, and Fructose”). 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
232 | Introduction
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 4.2 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.
Introduction | 233
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.
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 4.3 The Most Common Disaccharides
Image by
Allison
Calabrese /
CC BY 4.0
234 | Introduction
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.
Figure 4.4 Structures of the Plant Starches and Glycogen
Introduction | 235
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
2
cardiovascular disease.
2. US Department of Agriculture. Part D. Section 5:

Carbohydrates. In Report of the DGAC on the Dietary
Guidelines for Americans, 2010.
http://www.cnpp.usda.gov/Publications/
236 | Introduction
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 4.5 Dietary Fiber
DietaryGuidelines/2010/DGAC/Report/
D-5-Carbohydrates.pdf. Accessed September 30, 2011.
Introduction | 237
Image by
Allison
Calabrese /
CC BY 4.0
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238 | Introduction


Introduction | 239
Digestion and Absorption of
Carbohydrates
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 4.6 Salivary Glands in the Mouth
240 | Digestion and Absorption of

Carbohydrates
Salivary
glands
secrete
salivary
amylase,
which begins
the chemical
breakdown
of
carbohydrate
s by breaking
the bonds
between
monomeric
sugar units.
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
Digestion and Absorption of Carbohydrates | 241

chemically broken down into single sugar units they are then
transported into the inside of intestinal cells.
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
1
European descent have the least. 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,
1. Lactose Intolerance. National Digestive Diseases

Information Clearing House.
http://digestive.niddk.nih.gov/ddiseases/pubs/
lactoseintolerance/. Updated April 23, 2012. Accessed
September 22, 2017.
242 | Digestion and Absorption of Carbohydrates

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 4.7 Carbohydrate Digestion
Carbohydrat
e digestion
begins in the
mouth and is
most
extensive in
the small
intestine.
The resultant
monosacchar
ides 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
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 4.8 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.
Figure 4.9 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.
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
2
of obesity, Type 2 diabetes, and cardiovascular disease.
2. Brand-Miller J, et al. (2009). Dietary Glycemic Index:

Table 4.1 The Glycemic Index: Foods In Comparison To Glucose
Health Implications. Journal of the American College of

Nutrition, 28(4),
446S–49S.https://www.ncbi.nlm.nih.gov/pubmed/

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
Rice milk 86
Cheerios 74
Raisin Bran 73
Fruit roll-up 99
Gatorade 78
For the Glycemic Index on different foods, visit

http://www.mendosa.com/gilists.htm.
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.
http://www.gilisting.com/
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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 Functions of Carbohydrates in

the Body | 253
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 4.10 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
254 | The Functions of Carbohydrates in the Body

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 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.
The Functions of Carbohydrates in the Body | 255

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 4.11 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 4.12 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 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.
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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
Figure 4.13 Sugar Consumption (In Teaspoons) From Various

Sources
Image by
Forluvoft /
Public
Domain
260 | Health Consequences and

Benefits of High-Carbohydrate Diets
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
1
percent of total calories in 2000.
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 “Sugar Consumption (in
Teaspoons) from Various Sources”).
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
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.
Health Consequences and Benefits of High-Carbohydrate Diets | 261

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 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
2
gain and obesity. A study at the Harvard School of Public Health
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),
262 | Health Consequences and Benefits of High-Carbohydrate Diets

linked the consumption of sugary soft drinks to an increased risk for
3
heart disease.
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
4
dietary recommendations :
• 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.
274–88. http://www.ajcn.org/content/84/2/274.long.
3. Public Health Takes Aim at Sugar and Salt. Harvard
School of Public Health. https://www.hsph.harvard.edu/
news/magazine/sugar-and-salt/. Published 2009.
4. Van Horn L, Johnson RK, et al.(2010). Translation and
Implementation of Added Sugars Consumption
Recommendations. Circulation, 122,
2470–90.http://circ.ahajournals.org/content/122/23/
2470/tab-supplemental. Accessed September 27, 2017.

• 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
5
glucose metabolism especially in people with Type 2 diabetes.
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
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. http://www.ajcn.org/
content/76/5/911.full. Accessed September 27, 2017.

Journal concluded that all diets, (independent of carbohydrate, fat,
and protein content) that incorporated an exercise regimen
significantly decreased weight and waist circumference in obese
6
women.
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
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).
PMC3000832/ . Accessed September 27, 2017.

meal (see Figure 4.14 “Fibers Role in Carbohydrate Digestion and
Absorption”) 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 4.14 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
7
getting Type 2 diabetes by 21 percent. The Nurses’ Health Study
found that women who consumed two to three servings of whole
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. https://www.ncbi.nlm.nih.gov/
pubmed/17760498. Accessed September 27, 2017.

grain products daily were 30 percent less likely to have a heart
8
attack.
9
The AHA makes the following statements on whole grains :
• “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.”
Figure 4.15 Grain Consumption Statistics in America
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. http://www.ajcn.org/
content/70/3/412.long. Accessed September 27, 2017.
9. Whole Grains and Fiber. American Heart Association.
http://www.heart.org/HEARTORG/GettingHealthy/
NutritionCenter/HealthyDietGoals/Whole-Grains-and-
Fiber_UCM_303249_Article.jsp. Updated 2017. Accessed
September 30, 2017.

Source: Economic Research Service. http://www.ers.usda.gov/
data-products/commodity-consumption-by-population-
characteristics/documentation.aspx.
Learning Activities

Open Document).




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 4.2 Dietary Reference Intakes For Carbohydrates And Fiber
Carbohydrates and Personal Diet

Choices | 271
AMDR (%
Carbohydrate Type RDA (g/day)
calories)
Total Carbohydrates 130 45–65
Added Sugars < 25
38 (men),* 25
Fiber
(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 “Carbohydrates in Foods
(grams/serving)” gives the specific amounts of carbohydrates, fiber,
and added sugar of various foods.
Table 4.3 Carbohydrates in Foods (grams/serving)
272 | Carbohydrates and Personal Diet Choices

Total Added
Foods Sugars Fiber
Carbohydrates 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
58 (100 g) 0.50 10.0 0
(homemade)
Skim milk 12 (1 c.) 12.00 0 0
Cream (half and

0.65 (1 Tbs.) 0.02 0 0
half)
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. http://www.nal.usda.gov/fnic/
foodcomp/search/. Updated December 7, 2011. Accessed
September 17, 2017.
• Database for the Added Sugars Content of Selected Foods. US
Department of Agriculture. http://www.nal.usda.gov/fnic/
foodcomp/search/. Published February 2006. Accessed
Carbohydrates and Personal Diet Choices | 273

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 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 4.4 “Food Labels Pertaining to Carbohydrates”).
Table 4.4 Food Labels Pertaining to Carbohydrates
Label Meaning
Sugar-free Contains less than 0.5 grams of sugar per serving
Reduced
Contains 25 percent less sugar than similar product
sugar
Contains 25 percent less sugar than similar product, and
Less sugar
was not altered by processing to become so
No sugars
No sugars added during processing
added
Contains at least 20 percent of daily value of fiber in each
High fiber
serving
A good
Contains between 10 and 19 percent of the daily value of
source of
fiber per serving
fiber
Contains 10 percent or more of the daily value of fiber per
More fiber
serving
Source: Appendix A: Definitions of Nutrient Claims. Guidance for

Industry: A Food Labeling Guide. US Food and Drug Administration.
http://www.fda.gov/Food/
GuidanceComplianceRegulatoryInformation/
GuidanceDocuments/FoodLabelingNutrition/FoodLabelingGuide/
ucm064911.htm. 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.
• 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 “Relative
Sweetness of Sugar Substitutes”). 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 4.5 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 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
1
National Toxicology Program’s list of potential carcinogens.
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
1. Artificial Sweeteners and Cancer. National Cancer

Institute. http://www.cancer.gov/cancertopics/
factsheet/Risk/artificial-sweeteners. Updated August 5,

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 4.6 “Sweeteners”.
Table 4.6 Sweeteners

Sweeteners
Consumer Controversial
with Trade Calories Source/Origin
Recommendations Issues
Name
FDA set maximum

Acceptable Daily
Intakes (ADI):50
mg/kg body Children have
Composed of two
weight = 16 12 oz. potential to reach
Aspartame amino acids
diet soft drinks ADI if consuming
(phenylalanine +
for adults. many beverages,
aspartic acid) +
• NutraSweet 4 kcal/g desserts, frozen
methanol.Two
• Equal *Cannot be used desserts, and
hundred times
in products gums containing
sweeter than
requiring cooking. aspartame
sucrose.
People with routinely.
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
• protest
Discovered in 1878.
launched by
Saccharin The basic
consumer &
substance is ADI: 5 mg/kg
interest
benzoic body weight.*Can
• Sweet ‘n’ 0 kcal/g groups
sulfinide.Three be used in
Low • warning label
hundred times cooking.
listed on
sweeter than
products
sucrose.
about
saccharin and
cancer risk in
animals until
2001 when
studies
concluded
that it did not
cause cancer
in humans

Discovered in 1967.
Composed of an
organic salt,
potassium (K).
Structure is very
Acesulfame K similar to ADI: 15 mg/kg
saccharin’s.It body weight.Body
passes through the cannot digest it.
• Sunnette 0 kcal/g
body unchanged
• Sweet One
which means it *Can be used in
does not provide cooking.
energy.
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
Cyclamates Thirty times in all food and
sweeter than beverage products
0 kcal/g No ADI available.
• Sugar Twin sucrose.Discovered within the United
in 1937. 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.

First discovered in
1976. Approved for
use in 1998 in the
United States and
in 1991 in
1
Canada.Derived
Sucralose Splenda
from sucrose in ADI: 5 mg/kg
packet
which three of its body weight.*Can
contains
• Splenda hydroxyl (OH) be used in
3.31
groups are cooking.
calories
replaced by
= 1g
chlorine (Cl−).
Six hundred times

sweeter than
sugar.
Used sparingly,
stevia may do little
harm, but FDA
Classified as
could not approve
Stevioside GRAS.Considered
Derived from extensive use of
to be a dietary
stevia plant found this sweetener due
supplement and
• Stevia N/A in South America. to concerns
approved not as
• Sweet Leaf Stevia rebaudiana regarding its effect
an additive, but as
leaves. on reproduction,
a dietary
cancer
supplement.
development, and
energy
metabolism.

It is illegal to sell
true raw sugar in
the United States
because when raw
it contains dirt Over-consumption
and insect parts, has been linked to
Extracted from
Sucrose as well as other several health
either sugar beets
byproducts. Raw effects such as
~4 kcal/ or sugar cane,
sugar products tooth decay or
• Sugar g which is then
sold in the United dental caries and
purified and
States have contributes to
crystallized.
actually gone increased risk for
through more chronic diseases.
than half of the
same steps in the
refining process
as table sugar.
*Considered safe
for baking and
cooking.Infants
under twelve
months old should
not be given
Made from
honey because
sucrose. Contains
their digestive
nectar of flowering
tracts cannot
plants. Made by
handle the
bees. Sucrose is
bacteria found in
Honey 3 kcal/g fructose + glucose;
honey. Older
however, honey
children and
contains more
adults are
calories than
immune to these
sucrose because
effects. Honey
honey is denser.
contains some
harmful bacteria
that can cause
fatal food
poisoning in
infants.

Controversial
because it is found
HFCS ubiquitously in
Dry Corn is milled to
processed food
form: 4 produce corn
products, which
• high kcal/g; starch, then the
could lead to
fructose Liquid cornstarch is
overconsumption.
corn syrup form: 3 further processed
Study results are
kcal/g to yield corn syrup.
varied regarding
its role in chronic
disease.
Sugar Alcohols Less likely to May cause

2–4
Sugar cause tooth decay diarrhea and
kcal/
• Sorbitol alcohols.Sorbitol is than gastrointestinal
g.Not
• Xylitol derived from sucrose.Sugar distress if
calorie
• Mannitol glucose. alcohols have a consumed in large
free
laxative effect. amounts.
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
2
any risk from the use of any substance.”
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
Learning Activities

2. Overview of Food Ingredients, Additives and Colors. US

Food and Drug Administration. https://wayback.archive-
it.org/7993/20170722025446/https://www.fda.gov/
Food/IngredientsPackagingLabeling/
FoodAdditivesIngredients/ucm094211.htm. Updated
April 2010. Accessed September 22, 2017.

Open Document).



PART V
CHAPTER 5. LIPIDS
Chapter 5. Lipids | 289

Introduction
E hinu auaneʻi na nuku, he pōmaikaʻi ko laila
Where the mouths are shiny with fat food, prosperity is there
Image by Phu
Thinh Co /
CC BY-SA 2.0
Introduction | 291
Learning Objectives
• 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
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,
1
protection from the wind, and coastal erosion control. 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
1. Snowdon W, Osborn T. (2003). Coconut: It’s role in

health. Secretariat of the Pacific.
292 | Introduction
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.
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.
Introduction | 293
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 5.1 Types of Lipids
Image by
Allison
Calabrese /
CC BY 4.0
Learning Activities

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294 | Introduction

Introduction | 295
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
296 | The Functions of Lipids in the

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
The Functions of Lipids in the Body | 297

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. 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 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 5.2 Food Sources of Omega 3’s
298 | The Functions of Lipids in the Body

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.
Learning Activities

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The Functions of Lipids in the Body | 299



300 | The Functions of Lipids in the Body

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.
The Role of Lipids in Food | 301

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.
302 | The Role of Lipids in Food

Tools for Change
There are many

sources of omega-3 foods.
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.
The Role of Lipids in Food | 303

Learning Activities

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304 | The Role of Lipids in Food

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.
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 5.3 The Structure of a Triglycerides
Image by
Allison
Calabrese/
CC BY 4.0
How Lipids Work | 305

Fatty Acids
Fatty acids determine if the compound is solid or liquid at room

temperature. Fatty acids consist of a carboxylic acid (−COOH) group
on one end of a carbon chain and a methyl group (−CH3) 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.
Figure 5.4 Structures of a Saturated, Monounsaturated, and
Polyunsaturated Fat
306 | How Lipids Work

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
1
weight gain as compared to other fatty acids.
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
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.

monounsaturated fats and polyunsaturated fats provide nutrition
that is essential for normal cell development and healthy skin.
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.
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
2
cholesterol levels.
Figure 5.5 Structures of Saturated, Unsaturated, Cis and Trans
fatty Acids
2. Introduction to “Fats and Cholesterol: Out with the Bad,

In with the Good” The Nutrition Source. Harvard School
of Public Health. http://www.hsph.harvard.edu/
nutritionsource/what-should-you-eat/fats-full-
story/#references. Updated 2017. Accessed September
28, 2017.

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
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.

Learning Activities

Open Document).



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
Nonessential and Essential Fatty

Acids | 313
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 5.6 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
314 | Nonessential and Essential Fatty Acids

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.
Figure 5.7 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
Nonessential and Essential Fatty Acids | 315

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 5.8 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,
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 5.9 The Structure of Cholesterol
“Cholesterol
Chemical
Structure” by
Wesalius /
Public
Domain
Learning Activities

Open Document).

Nonessential and Essential Fatty Acids | 317



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?
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 5.10 Lipid Digestion and Absorption

Lipids | 319
Illustrated diagram of human body showing lipid Image by
Allison
digestion and absorption. 1. Small amount of lipid Calabrese /
digestion occurs in stomach due to gastric lipase CC BY 4.0
produced in stomach 2. Bile produced in liver, stored
in gallbladder, release into small intestine to aid
digestion and absorption of lipids. 3. Pancreatic lipase
produced by pancreas and released into small
intestine to break down triglycerides, fatty acids, and
glycerol. 4. In small intestine products from fat
digestion and bile acids form micelle, which moves
towrad the microvilli allowing lipids to diffuse into
mucosal cells. 5. Inside mucuosal cell, fatty acids and
monoglycerides reassembled into triglycerides and
incorporated into lipids transport particles called
chylomicrons, which enter the lymph vessel.
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
320 | Digestion and Absorption of Lipids

cholesterol so it acts as an emulsifier. It attracts and holds onto
fat while it is simultaneously attracted to and held on to by 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 5.11 Micelle Formation
Scheme of a
micelle
formed by
phospholipid
s in an
aqueous
solution by
Emmanuel
Boutet / CC
BY-SA 3.0
Figure 5.12 Schematic Diagram Of A Chylomicron
Digestion and Absorption of Lipids | 321

Chylomicron
s 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 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 5.13 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.
Figure 5.14 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.
• 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 5.15 Lipoprotein Classes

https://www
.intechopen.c
om/books/
lipoproteins-
role-in-healt
h-and-diseas
es/
pathophysiol
ogy-of-lipopr
otein-oxidati
on
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 risk.The University of Maryland Medical Center reports
that omega-3 fatty acids promote lower total cholesterol and lower
1
triglycerides in people with high cholesterol.
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. http://www.umm.edu/altmed/articles/
omega-3-000316.htm. Updated August 5, 2015. Accessed
September 28, 2017.

Learning Activities

Open Document).





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.
Tools for Change | 331

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
1
total cholesterol values are used to target treatment
• 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)
1. High Blood Cholesterol: What You Need to Know.

National Heart, Lung, and Blood Institute, National
Institutes of Health. NIH Publication.
http://www.nhlbi.nih.gov/health/public/heart/chol/
wyntk.htm. Updated June 2005.Accessed September 28,
2017.
332 | Tools for Change

• 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
2
follows :
• 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.
• Consume fewer than 10 percent of calories from saturated fats.

Some studies suggest that lowering the saturated fat content
2. Dietary Reference Intakes: Macronutrients. Institute of

Medicine. https://www.nal.usda.gov/sites/default/
files/fnic_uploads/DRIEssentialGuideNutReq.pdf.
Published 2006. Accessed September 28, 2017.

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
3
oily fish, at least twice per week.
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
3. Fish and Omega-3 Fatty Acids. American Heart

Association. https://healthyforgood.heart.org/Eat-
smart/Articles/Fish-and-Omega-3-Fatty-Acids.
Updated March 24, 2017. Accessed October 5, 2017.

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 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.
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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
340 | Lipids and the Food Industry

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?
Lipids and the Food Industry | 341

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
• 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 water and 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,
Lipids and the Food Industry | 343

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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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
Lipids and Disease | 345

1
increases by 23 percent . 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
1. Fats and Cholesterol: Out with the Bad, In with the

Good. Harvard School of Public Health.
http://www.hsph.harvard.edu/nutritionsource/what-
should-you -eat/fats-full-story/. Updated 2017.
346 | Lipids and Disease

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.
• 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
2
disease among younger children has doubled .
• 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
2. Childhood Obesity. US Department of Health and

Human Services. http://aspe.hhs.gov/health/reports/
child_obesity/. Published May 1, 2005. Accessed
October 5, 2012.

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.
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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
A Personal Choice about Lipids | 351

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
352 | A Personal Choice about Lipids

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.
• 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.
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354 | A Personal Choice about Lipids



PART VI
CHAPTER 6. PROTEIN
Chapter 6. Protein | 357

Introduction
He pūkoʻa kani ʻāina
A coral reef that grows into an island
Ahi poke by
Arnold
Gatilao / CC
BY 2.0
Learning Objectives
• Describe the role and structure of proteins

• Describe the functions of proteins in the body
• Describe the consequences of protein imbalance
Introduction | 359
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
1
poke but ahi (tuna) fish is typically the most desirable option.
Your protein-rich muscles allow for body strength and
movement, which enable you to enjoy many activities.
1. Fish Preparation/Eating. HawaiiHistory.org.

http://www.hawaiihistory.org/index.cfm?PageID=382.
Updated 2017. Accessed October 30, 2017.
360 | Introduction
William
Hook
https://unspl
ash.com/
photos/
pa0rr3rVB-
U
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Introduction | 361
362 | Introduction
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.”
Defining Protein | 363

Amino acids differ from each other by which specific side chain is
bonded to the carbon center.
Figure 6.1 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.
Figure 6.2 The Different Groups of Amino Acids
364 | Defining Protein

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 6.1 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 “Formation of Polypeptides”). Additionally,
proteins come in many 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 6.3 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.
Figure 6.4 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.
Figure 6.5 The Four Structural Levels of Proteins

Image by
OpenStax /
CC BY 4.0
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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.
374 | The Role of Proteins in Foods:

Cooking and Denaturation
Image by
Annie Spratt
on
unspash.com
/ 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).
The Role of Proteins in Foods: Cooking and Denaturation | 375

Figure 6.6 Protein Denaturation
When a
protein is
exposed to a
different
environment
, such as
increased
temperature,
it unfolds
into a single
strand of
amino acids.
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376 | The Role of Proteins in Foods: Cooking and Denaturation

The Role of Proteins in Foods: Cooking and Denaturation | 377

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 6.7 “Digestion and
Absorption of Protein”). 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 6.7 Digestion and Absorption of Protein
Image by
Allison
Calabrese /
CC BY 4.0
378 | Protein Digestion and

Absorption
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.
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
Protein Digestion and Absorption | 379

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 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
380 | Protein Digestion and Absorption

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 6.8 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.
Protein Digestion and Absorption | 381

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382 | Protein Digestion and Absorption

Protein’s Functions in the
Body
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
Figure 6.9 Collagen Structure
Protein’s Functions in the Body | 383

Collagen
Triple Helix
by Nevit
Dilmen / CC
BY-SA 3.0
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
384 | Protein’s Functions in the Body

and the ability of these tissues to spring back after a movement is
complete.
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 (see Figure 6.10 “Enzymes Role in
Carbohydrate Digestion”).
Figure 6.10 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.
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 6.11 The Protein Albumin
PDB 1o9x EBI
by Jawahar
Swaminatha
n and MSD
staff at the
European
Bioinformati
cs Institute /
Public
Domain The
butterfly-sha
ped 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
Figure 6.12 Antibody Proteins

Abagovomab
(monoclonal
antibody) by
Blake C / CC
BY-SA 3.0
Figure 6.13 Antigens

Antibody
chains by
Fred the
Oyster /
Public
Domain
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.
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.
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 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 “Amino Acids Used for Energy”). 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 6.14 Amino Acids Used for Energy

Image by
Allison
Calabrese /
CC BY 4.0
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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,
Diseases Involving Proteins | 395

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 6.15 A Young Boy With Kwashiorkor
396 | Diseases Involving Proteins

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.
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 6.16 Children With Marasmus
Japanese
nurse with
dependent
children
having
typical
appearance
of
malnutrition
, New Bilibid
Prison,
September-O
ctober 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.
Figure 6.17 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
1
cancer risk. Although there are a few ideas, the exact mechanism of
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.

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
23
higher risk for wrist fracture.
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
4
to any conclusions about the association between the two.
http://dx.plos.org/10.1371/journal.pone.0020456.
2. Protein: The Bottom Line. Harvard School of Public
Health.The Nutrition Source.
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.long. 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.

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
5
abnormalities overall.”
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.
http://circ.ahajournals.org/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.
http://circ.ahajournals.org/cgi/
September 28, 2017.

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Proteins in a Nutshell
Image by
Braden
Collum on
unsplash.co
m / CC0
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
Proteins in a Nutshell | 405

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?
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, http://www.soystache.com/
protein.htm.
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;
406 | Proteins in a Nutshell

• 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.
• 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.
Learning Activities

Open Document).
Proteins in a Nutshell | 407


408 | Proteins in a Nutshell

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 6.2 “Dietary Reference Intakes for Protein”. 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 6.2 Dietary Reference Intakes for Protein
Proteins, Diet, and Personal

Choices | 409
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
410 | Proteins, Diet, and Personal Choices

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 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
1
package that’s likely to make a difference.”
1. Protein: The Bottom Line. Harvard School of Public
Proteins, Diet, and Personal Choices | 411

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 6.3 “Sources of Dietary Protein”. To find out
the complete nutrient package of different foods, visit the US
Department of Agriculture (USDA) Food Composition Databases.
Table 6.3 Sources of Dietary Protein
Health. The Nutrition Source.

should-you-eat/protein/. Published 2012. Accessed
September 30, 2017.

Protein Saturated Cholesterol
Food Calories
Content (g) Fat (g) (mg)
Hamburger patty 3
22.0 5.7 77 230
oz. (80% lean)
Hamburger patty 3
22.0 2.3 60 139
oz. (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
56.4 22.2 222 790
style, 1 piece)
Chicken breast
43.4 1.4 119 231
(roasted, 1 c.)
Chicken thigh
13.5 1.6 49 109
(roasted, 1 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,
18.9 5.4 200 454
fried, 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.
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 6.18 Complete and Incomplete Protein Sources

Protein-rich
Foods by
Smastronard
o / 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 6.4
“Complementing Protein Sources the Vegan Way”. 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 6.4 Complementing Protein Sources the Vegan Way

Lacking Amino Complementary Complementary
Foods
Acids Food Menu
Methionine, Grains, nuts, Hummus and
Legumes
tryptophan and seeds whole-wheat pita
Lysine, isoleucine, Cornbread and
Grains Legumes
threonine kidney bean chili
Nuts and Stir-fried tofu with
Lysine, isoleucine Legumes
seeds 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 6.5 “PDCAAS of Various Foods”.
Table 6.5 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
2
dietary guidelines for all nutrients.
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 “Percentage of “Meat and Beans Group” Components
in the USDA Base Diet, and Three Vegetarian Variations” and Table
7.7 “Proportions of Milk Products and Calcium-Fortified Soy
Products in the Base USDA Patterns and Three Vegetarian
Variations” 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
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). http://ajcn.nutrition.org/
content/89/5/1549S.short.

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 6.6 Percentage of “Meat and Beans Group” Components in
the USDA Base Diet, and Three Vegetarian Variations
Base USDA Plant-Based Lacto-Ovo Vegan

Food Category
(%) (%) Vegetarian (%) (%)
Meats 44.6 10.5 0 0

Poultry 27.9 8.0 0 0
Fish (high
2.2 3.0 0 0
omega-3)
Fish (low
7.1 10.0 0 0
omega-3)
Eggs 7.9 7.6 10.0 0
Soy products 0.9 15.0 30.0 25.0

Nuts and
9.4 20.9 35.0 40.0
seeds
Dry beans and
n/a* 25.0 25.0 35.0
peas
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.
http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/

DGAC/Report/AppendixE-3-3-Vegetarian.pdf. Accessed
September 28, 2017.
Table 6.7 Proportions of Milk Products and Calcium-Fortified Soy

Products in the Base USDA Patterns and Three Vegetarian
Variations
Base Plant-based Lacto-ovo Vegan

Food Category
USDA (%) (%) vegetarian (%) (%)
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/
1.1 1.1 1.1 67.0
calcium)
Rice milk (w/
0 0 0 16.0
calcium)
Tofu (w/
0 0 0 15.0
calcium)
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.
http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/
DGAC/Report/AppendixE-3-3-Vegetarian.pdf. 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
3
aging adults from becoming sarcopenic.
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
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.
http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC2938033/?tool=pubmed. Accessed September 28,
2017.

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
4
have the following position statements :
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
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. http://journals.lww.com/acsm-msse/
fulltext/2009/03000/
Nutrition_and_Athletic_Performance.27.aspx. Accessed
September 28, 2017.

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 6.8 Snacks for Exercise Recovery
Protein Carbohydrates
Foods Calories
(g) (g)
Whole grain cereal with nonfat

14 53 260
milk
Medium banana with nonfat milk 10 39 191
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
5
body mass.”
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
6
effects of taking branched-chain amino acids.
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. http://journals.lww.com/acsm-msse/
fulltext/2009/03000/
September 28, 2017.
6. Gleeson, M. (2005). Interrelationship between Physical

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,
Activity and Branched-Chain Amino Acids. Journal of

Nutrition, 135(6), 1591S–5S. http://jn.nutrition.org/
content/135/6/1591S.long. Accessed October 1, 2017.

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.
Learning Activities


Open Document).



PART VII
CHAPTER 7. ALCOHOL
Chapter 7. Alcohol | 429

Introduction
Ka wai hoʻomalule kino
The liquid that causes limpness to the body
Image by
Allison
Calabrese /
CC BY 4.0
Learning Objectives
Introduction | 431
• Describe the process of alcohol metabolism
• Describe the health benefits and health risks
associated with alcohol consumption
Alcohol is both a beverage providing some sustenance and a drug.

For thousands of years, alcohol has been consumed in a medicinal,
celebratory, and ritualistic manner. It is drunk in just about every
country and often in excessive amounts. Alcohol can be made from
a variety of different starch foods through the processes called
fermentation. Fermentation of a starchy food such as barley or
wheat can produce ethanol and CO2 which makes up what is
commonly known as beer. The Native Hawaiians distilled a mash of
fermented ti roots in iron try-pots pre-colonization in the 1700s.
This form of alcohol was called “Okolehao”. This alcoholic beverage
more commonly known today as “moonshine”, is still made locally in
1
the islands today.
Alcohol is a psychoactive drug. A psychoactive drug is any
substance that crosses the blood-brain barrier primarily affecting
the functioning of the brain, be it altering mood, thinking, memory,
motor control, or behavior. Alcohols in chemistry refer to a group
of similar organic compounds, but in beverages the only alcohol
consumed is ethanol.
The Behavioral Risk Factor Surveillance System survey reported
that more than half of the adult US population drank alcohol in
1. Hoover, W. (2003). Will New ‘Okolehao be your cup of

Ti?. Honolulu Advertiser.com
http://the.honoluluadvertiser.com/article/2003/Jun/
01/ln/ln05a.html. Published June 1, 2003. Accessed
November 10, 2017.
432 | Introduction
2
the past thirty days. Of the total population who drank alcohol,
approximately 5 percent drank heavily, while 15 percent binge
drank. Binge drinking (as defined by the National Institute on
Alcohol Abuse and Alcoholism) is when men consume five or more
drinks, and when women consume four or more drinks, in two
3
hours or less.
Alcohol in excess is detrimental to health; however since its
beginnings it has been suspected and promoted as a benefit to the
body and mind when consumed in moderation. In the United States,
the Dietary Guidelines define moderate alcohol intake as no more
than one drink per day for women and no more than two drinks per
4
day for men. Although drunkenness has pervaded many cultures,
drinking in moderation has long been a mantra of multiple cultures
with access to alcohol.
More than 90 percent of ingested alcohol is metabolized in the
liver. The remaining amount stays in the blood and is eventually
excreted through the breath (which is how Breathalyzers work),
urine, saliva, and sweat. The blood alcohol concentration (BAC) is
measured in milligrams percent, comparing units of alcohol to units
of blood. BAC is a measurement used legally to assess intoxication
2. Alcohol and Public Health. Centers for Disease Control

and Prevention. http://www.cdc.gov/alcohol/. Updated
March 5, 2012. Accessed October 1, 2017.
3. Alcohol and Public Health. Centers for Disease Control
and Prevention. http://www.cdc.gov/alcohol/. Updated
March 5, 2012. Accessed October 1, 2017.
4. Alcoholic Beverages.US Department of Agriculture and
US Department of Health and Human
Services.http://www.health.gov/DIETARYGUIDELINES/
dga2005/document/html/chapter9.htm. Published
2005. Accessed October 5, 2017.
Introduction | 433
and the impairment and ability to perform certain activities, as
in driving a car. As a general rule, the liver can metabolize one
standard drink (defined as 12 ounces of beer, 5 ounces of wine, or 1
½ ounces of hard liquor) per hour. Drinking more than this, or more
quickly, will cause BAC to rise to potentially unsafe levels. Table 10.1
“Mental and Physical Effects of Different BAC Levels” summarizes
the mental and physical effects associated with different BAC levels.
Table 7.1 Mental and Physical Effects of Different BAC Levels
BAC
Typical Effects
Percent
Some loss of judgment, altered mood, relaxation, increased

0.02
body warmth
Exaggerated behavior, impaired judgment, may have some loss
0.05 of muscle control (focusing eyes), usually good feeling, lowered
alertness, release of inhibition
Poor muscle coordination (balance, speech, vision, reaction
0.08 time), difficulty detecting danger, and impaired judgment,
self-control, reasoning, and memory
Clear deterioration of muscle control and reaction time,
0.10
slurred speech, poor coordination, slowed thinking
Far less muscle control than normal, major loss of balance,
0.15
vomiting
In addition to the one drink per hour guideline, the rate at which an
individual’s BAC rises is affected by the following factors:
• Sex (A woman’s BAC will rise more quickly than a man’s.)

• Weight (BAC will rise more slowly for heavier people.)
• Genetics
• Length of time as a heavy drinker
• Type of alcohol consumed
• Amount of alcohol consumed
• Consumption rate
• Consumption before or after a meal (food in the stomach slows
absorption)
434 | Introduction
• Mixture (carbonated mixers speed absorption)
• Medications may increase the bioavailability of alcohol
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Introduction | 435
Alcohol Metabolism
Image by
Serge Esteve
on
unsplash.co
m / CC0
Giving the liver enough time to fully metabolize the ingested alcohol
is the only effective way to avoid alcohol toxicity. Drinking coffee
or taking a shower will not help. The legal limit for intoxication
is a BAC of 0.08. Taking into account the rate at which the liver
metabolizes alcohol after drinking stops, and the alcohol excretion
rate, it takes at least five hours for a legally intoxicated person to
achieve sobriety.
Figure 7.1 Alcohol Metabolism Summary
436 | Alcohol Metabolism

Figure 7.1
Alcohol
Metabolism
Summary
Ethanol Consumption
Distilled spirits have exceptionally few nutrients, but beer and wine
do provide some nutrients, vitamins, minerals, and beneficial plant
chemicals along with calories. A typical beer is 150 kilocalories, a
glass of wine contains approximately 80 kilocalories, and an ounce
of hard liquor (without mixer) is around 65 kilocalories.
As a person starts drinking alcohol, up to 5% of the ingested
ethanol is directly absorbed and metabolized by some of cells of the
gastrointestinal tract (the mouth, tongue, esophagus and stomach).
Up to 100% of the remaining ethanol travels in circulation. This is
one reason why blood tests are more accurate in measuring alcohol
levels.
The lungs and kidneys will excrete about 2% to 10% of this
circulatory ethanol. The more you drink the more quick trips to the
restroom. The human body dehydrates as a result of these frequent
trips to the restroom. This dehydration affects every single cell in
Alcohol Metabolism | 437

your body, including your brain cells. This is the cause of the so-
called “morning hangover”. Do not take Tylenol (acetaminophen).
Alcohol metabolism activates an enzyme that transforms
acetaminophen into a toxic metabolite that causes liver
inflammation and damage. Liver damage may not be irreversible.
Instead, drink water with electrolytes or sport drinks to rehydrate
the body’s cells.
Alcohol is a volatile (flammable) organic substance and can be
converted to a gas. The lungs exhale alcohol as a gas. The more
alcohol consumed, the stronger the smell of alcohol in a person’s
breathe. Breathalyzer tests measure the exhaled alcohol levels in the
lungs to determine the state of inebriation.
The liver metabolizes up to 85% – 98% of the circulatory ethanol.
The liver uses two metabolic processes to get rid of this circulatory
ethanol as quickly and safely as possible.
1. Alcohol dehydrogenase system

2. Microsomal ethanol oxidizing system (MEOS)
Alcohol Dehydrogenase System
About 80 to 90% of the total hepatic ethanol uptake is processed

via the alcohol dehydrogenase system. The degradation of ethanol
begins in the liver. The enzyme that catalyzes this reaction is called
alcohol dehydrogenase. The products from this reaction are
acetaldehyde, NADH (a reduced coenzyme that carries electrons
from one reaction to another) and H+ ion. Acetaldehyde is very
toxic to the liver and the body’s cells. The moment acetaldehyde is
produced; it must be degraded to protect the liver cells. The enzyme
that will carry this type of degradation reaction is acetaldehyde
dehydrogenase (ALDH). Acetaldehyde dehydrogenase converts
acetaldehyde into acetate, a non-toxic molecule.

Microsomal Ethanol Oxidizing System
(MEOS)
In a moderate drinker, about 10 to 20% of the total liver ethanol

uptake is processed via the microsomal ethanol oxidizing system
(MEOS). During periods of heavy drinking, the MEOS system will
metabolize most of the excess ethanol ingested. Heavy drinking
stimulates the human body to include the MEOS system enzymes to
clear ethanol faster from the body.
The MEOS system is also located in the liver. Similar to the
Alcohol dehydrogenase system, acetaldehyde dehydrogenase will
immediately convert acetaldehyde into acetate, a non-toxic
molecule. Other products from this reaction are NADH and H+ ion.
Fate of Acetate
The acetate produced (from the alcohol dehydrogenase system and

microsomal ethanol oxidizing system) is either released into
circulation or retained inside the liver cells. In the liver cells, acetate
is converted to acetyl CoA where it is used to produce other
molecules like CO2 or used in the synthesis of fatty acids and
cholesterol.

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Health Consequences of
Alcohol Abuse
Alcoholic drinks in excess contribute to weight gain by substantially

increasing caloric intake. However, alcohol displays its two-faced
character again in its effects on body weight, making many scientific
studies contradictory. Multiple studies show high intakes of hard
liquor are linked to weight gain, although this may be the result
of the regular consumption of hard liquor with sugary soft drinks,
juices, and other mixers. On the other hand drinking beer and, even
more so, red wine, is not consistently linked to weight gain and
in some studies actually decreases weight gain. The contradictory
results of scientific studies that have examined the association of
alcohol intake with body weight are partly due to the fact that
alcohol contributes calories to the diet. When alcohol is drunk in
excess, it reduces the secretion of pancreatic juice and damages the
lining of the gastrointestinal system, impairing nutrient digestion
and absorption. The impaired digestion and absorption of nutrients
in alcoholics contributes to their characteristic “skinniness” and
multiple associated micronutrient deficiencies. The most common
macronutrient deficiency among alcoholics is water, as it is
excreted in excess. Commonly associated micronutrient
deficiencies include thiamine, pyridoxine, folate, vitamin A,
magnesium, calcium, and zinc. Furthermore, alcoholics typically
replace calories from alcohol with those of nutritious foods,
sometimes getting 50 percent or more of their daily caloric intake
from alcoholic beverages.
442 | Health Consequences of

Alcohol Abuse
Effects of Alcohol Abuse on the Brain
A small amount (up to 10%) of the liver acetaldehyde may

accumulate inside the liver cells. As more alcohol is ingested, this
stimulates the production of acetaldehyde by both the alcohol
dehydrogenase and MEOS systems. As the levels of acetaldehyde
increase inside the liver cells with heavy consumption of alcohol,
some of the acetaldehyde diffuse into the blood circulation. In
circulation, high levels of acetaldehyde cause nausea and vomiting.
Vomiting causes more body dehydration and loss of electrolytes.
If the dehydration becomes severe enough, this can impair brain
function and a person may lose consciousness.
Alcohol can adversely affect nearly every area of the brain. When
BAC rises, the central nervous system is depressed. Alcohol disrupts
the way nerve cells communicate with each other by interfering
with receptors on certain cells. The immediate impact of alcohol
on the brain can be seen in the awkwardly displayed symptoms
of confusion, blurred vision, slurred speech, and other signs of
intoxication. These symptoms will go away once drinking stops,
but abusive alcohol consumption over time can lead to long-lasting
damage to the brain and nervous system. This is because alcohol
and its metabolic byproducts kill brain cells.
Effects of Excessive Alcohol on the Liver
Alcohol stimulates the release of epinephrine from the kidneys.

Epinephrine binds to receptors in the liver cells to stimulate the
release of glucagon from the pancreas. Glucagon and epinephrine
stimulate glycogenolysis in the liver cells. Epinephrine also
stimulates the breakdown of triglycerides and glycerol into free
fatty acids in adipose tissue and are released into the bloodstream
and travel to the liver.
Health Consequences of Alcohol Abuse | 443

A portion of these triglycerides are stored in the liver cells; while,
the remainder of these triglycerides are converted to very low
density lipoprotein (VLDL). The increased accumulation of both
stored triglycerides and VLDL particles inside the liver cells causes
a condition called fatty liver or hepatic steatosis. This can impair
normal liver function. The more alcohol consumed, the more lipids
produced and stored inside the liver cells. These effects are
cumulative over time.
According to the CDC, 14,406 Americans died from alcohol-
related liver diseases in 2007. Although not every alcoholic or heavy
drinker will die from liver problems, the liver is one of the body’s
main filtering organs and is severely stressed by alcohol abuse.
The term Alcoholic Liver Disease (ALD) is used to describe liver
problems linked to excessive alcohol intake. ALD can be progressive,
with individuals first suffering from a fatty liver and going on to
develop cirrhosis. It is also possible to have different forms of ALD
at the same time.
Figure 7.2 Liver Cirrhosis
Cirrosi
Micronodula
r by Amanda
Alvarez / CC
BY SY 4.0
Excessive alcohol consumption causes the destruction of liver cells.
444 | Health Consequences of Alcohol Abuse

In an attempt to repair itself, the liver initiates an inflammatory and
reparation process causing scar tissue to form. In the liver’s attempt
to replace the dead cells, surviving liver cells multiply. The result is
clusters of newly formed liver cells, also called regenerative nodules,
within the scar tissue. This state is called cirrhosis of the liver.
The three most common forms of ALD are:
• Fatty liver. A rather benign disorder that develops after

excessive alcohol consumption; however it can progress to
more fatal diseases. Fatty liver is reversible if alcohol use is
brought under control.
• Alcoholic hepatitis. The symptoms of this alcohol-induced liver
inflammation are a swollen liver, abdominal pain, nausea, fever,
jaundice, and vomiting. Although linked to alcohol use, even
people who drink moderately can sometimes develop this
condition, and not all alcohol abusers do. If a person stops
drinking alcohol, the liver damage can be reversed. But if they
continue, cirrhosis may develop and death can result.
• Cirrhosis. This serious and sometimes fatal form of ALD
develops when liver cells die and form scar tissue, which
blocks blood flow and causes wastes and toxins to build up in
the system. Strictly speaking, cirrhosis cannot be cured. It can,
however, be stopped with medical treatment and
complications can be managed if the individual stops drinking,
and many do survive. Not all cases of cirrhosis are strictly due
to alcoholism, and not all alcoholics develop the disease.
Symptoms of cirrhosis include the buildup of abdominal fluid
(ascites), abdominal pain, fever, thirst, confusion, and fatigue.
Figure 7.3 The Progression of ALD

Stages of
Liver
Damage by
National
Digestive
Diseases
Information
Clearinghous
e / Public
Domain
As the liver cells release VLDL particles into circulation, this

increases the levels of VLDL particles in blood. As VLDL particles
continue to accumulate in blood, this cause a condition called
hyperlipidemia. In their journey through circulation, VLDL particles
are eventually degraded to low density lipoproteins (LDL) particles.
LDL particles are also known as “bad cholesterol”. Higher levels
of LDL particles in circulation lead to the build-up of cholesterol
deposition plaques inside the walls of the blood vessels (known as
atherosclerosis). These plaques can impair or stop blood flow to the
cells. If an artery is blocked, the cells cannot make enough energy
and eventually stop working. If the artery remains blocked for more
than a few minutes, the cells may die. When a cardiac artery is
blocked, this causes a heart attack (acute myocardial infarction).
Depending on the length and severity of the blockage, damage to
the cardiac cells may be permanent and irreversible. Once the heart
structure and function is compromised, the more susceptible a
patient would be to suffer a second heart attack.
446 | Health Consequences of Alcohol Abuse

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Health Benefits of Moderate
Alcohol Intake
In contrast to excessive alcohol intake, moderate alcohol intake has

been shown to provide health benefits. The data is most convincing
for preventing heart disease in middle-aged and older people. A
review of twenty-nine studies concluded that moderate alcohol
intake reduces the risk of coronary heart disease by about 30
1
percent in comparison to those who do not consume alcohol.
Several other studies demonstrate that moderate alcohol
consumption reduces the incidences of stroke and heart attack, and
also death caused by cardiovascular and heart disease. The drop in
risk for these adverse events ranges between percent. Moreover,
there is some scientific evidence that moderate alcohol intake
reduces the risk for metabolic syndrome, Type 2 diabetes, and
gallstones. In addition to providing some health benefits, moderate
alcohol intake also serves as a digestive aid, a source of comfort and
relaxation, and inducing social interactions, thereby benefiting all
aspects of the health triangle. It has not been clearly demonstrated
that moderate alcohol consumption benefits younger populations,
and the risks of any alcohol consumption do not outweigh the
benefits for pregnant women, those who are taking medications
1. Ronksley PE, et al. (2011). Association of Alcohol

Consumption with Selected Cardiovascular Disease
Outcomes: A Systematic Review and Meta-Analysis.
British Medical Journal, 342, d671. http://www.bmj.com/
content/342/bmj.d671. Accessed October 5, 2017.
448 | Health Benefits of Moderate
Alcohol Intake
that interact with alcohol, and those who are unable to drink in
moderation.
The Reality
Alcohol is a diuretic that results in dehydration. It suppresses the

release of antidiuretic hormone and less water is reabsorbed and
more is excreted. Drinking alcohol in excess can lead to a
“hangover,” of which the majority of symptoms are the direct result
of dehydration.
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Health Benefits of Moderate Alcohol Intake | 449


450 | Health Benefits of Moderate Alcohol Intake

PART VIII
CHAPTER 8. ENERGY
Chapter 8. Energy | 451

Introduction
Hoʻā ke ahi, kōʻala ke ola

Light the fire for there is life-giving substance
Image
by G.E.
Ulrich, USGS
/ CC BY-SA
2.0
Learning Objectives
• Describe the body’s use, storage and balance of
Introduction | 453
energy
• Describe factors that contribute to weight
management
• Identify evidence-based nutritional
recommendations
Months and months of training lead up to one of the most

prestigious one-man (or woman) outrigger canoe paddling races in
the world, the Ka‘iwi Channel Solo World Championship. Athletes
from Hawai‘i and across the world paddle from the island of Molokai
to Oahu in the Ka‘iwi Channel, whose name carries the meanings
of its two core words “the bones.” The channel is said to be one of
the most treacherous bodies of water and depending on the ocean
conditions top paddlers finish between 3 1/2 and 6 hours. Paddlers
spend hours and hours each week training to physically prepare
their bodies and minds for the race but equally important is the
refueling that takes place off the water. Each paddler will say they
have their own “secret” training nutrition plan which may consist of
a specific food or drink they prefer, but the bottom line is that the
energy from carbohydrates, protein, and fat they ingest is required
to fuel their body for training, recovering and repairing so they are
able to continue to perform at high levels. Having a nutrition plan
for race day is equally important for achieving peak performance
and there are all sorts of products available with claims about
digestibility, energy-sustenance, and promises of optimal
performance results. Even with all of these highly specified and
formulated products many paddlers prefer to rely on what fueled
Native Hawaiians and other ancient voyager, poi. Poi, made of
watered down pa‘i‘ai or mashed kalo (taro) was considered a
voyaging staple and for many paddlers it continues to be. This easily
transported food contains water that supports hydration, energy-
rich carbohydrates, and for some serves as a connection to their
454 | Introduction
voyaging ancestors, making it a “go-to” for many paddlers as they
cross the Ka‘iwi Channel.
Energy is essential to life. Normal function of the human body
requires a constant input and output of energy to maintain life.
Various chemical components of food provide the input of energy to
the body. The chemical breakdown of those chemicals provides the
energy needed to carry out thousands of body functions that allow
the body to perform daily functions and tasks such as breathing,
walking up a flight of steps, and studying for a test.
Energy is classified as either potential or kinetic. Potential energy
is stored energy, or energy waiting to happen. Kinetic energy is
energy in motion. To illustrate this, think of an Olympic swimmer
standing at the pool’s edge awaiting the sound of the whistle to
begin the race. While he waits for the signal, he has potential
energy. When the whistle sounds and he dives into the pool and
begins to swim, his energy is kinetic (in motion).
In food and in components of the human body, potential energy
resides in the chemical bonds of specific molecules such as
carbohydrates, fats, proteins, and alcohol. This potential energy is
converted into kinetic energy in the body that drives many body
functions ranging from muscle and nerve function to driving the
synthesis of body protein for growth. After potential energy is
released to provide kinetic energy, it ultimately becomes thermal
energy or heat. You can notice this when you exercise and your
body heats up.
The Calorie Is a Unit of Energy
The amount of energy in nutrients or the amount of energy

expended by the body can be quantified with a variety of units
used to measure energy. In the US, the kilocalorie (kcal) is most
commonly used and is often just referred to as a calorie. Strictly
speaking, a kcal is 1000 calories. In nutrition, the term calories
Introduction | 455
almost always refers to kcals. Sometimes the kcal is indicated by
capitalizing calories as “Calories.” A kilocalorie is the amount of
energy in the form of heat that is required to heat one kilogram of
water one degree Celsius.
Most other countries use the kilojoule (kJ) as their standard unit
of energy. The Joule is a measure of energy based on work
accomplished – the energy needed to produce a specific amount of
force. Since calories and Joules are both measures of energy, one
can be converted to the other – 1 kcal = 4.18 kJ.
Estimating Caloric Content
The energy contained in energy-yielding nutrients differs because

the energy-yielding nutrients are composed of different types of
chemical bonds. The carbohydrate or protein in a food yields
approximately 4 kilocalories per gram, whereas the triglycerides
that compose the fat in a food yield 9 kilocalories per gram. A
kilocalorie of energy performs one thousand times more work than
a calorie. On the Nutrition Facts panel found on packaged food, the
calories listed for a particular food are actually kilocalories.
Estimating the number of calories in commercially prepared food
is fairly easy since the total number of calories in a serving of a
particular food is listed on the Nutrition Facts panel. If you wanted
to know the number of calories in the breakfast you consumed
this morning just add up the number of calories in each food. For
example, if you ate one serving of yogurt that contained 150 calories,
on which you sprinkled half of a cup of low-fat granola cereal that
contained 209 calories, and drank a glass of orange juice that
contained 100 calories, the total number of calories you consumed
at breakfast is 150 + 209 + 100 = 459 calories. If you do not have
a Nutrition Facts panel for a certain food, such as a half cup of
blueberries, and want to find out the amount of calories it contains,
go to Food-a-pedia, a website maintained by the USDA. For more
456 | Introduction
details on food composition data, go to the USDA Food Composition
Databases page.
An Organism Requires Energy and Nutrient

Input
Energy is required in order to build molecules into larger

macromolecules (like proteins), and to turn macromolecules into
organelles and cells, which then turn 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 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 oxygen
is required and the chemical energy of glucose is gradually released
in a series of chemical reactions. Some of this energy is trapped
in the molecule adenosine triphosphate (ATP) and some is lost as
heat. ATP can be used when needed to drive chemical reactions in
cells that require an input of energy. Cellular respiration requires
oxygen (aerobic) and it is provided as a byproduct of photosynthesis.
The byproducts of cellular respiration are carbon dioxide (CO2) and
water, which plants use to conduct photosynthesis again. Thus,
carbon is constantly cycling between plants and animals.
Introduction | 457
Figure 8.1 Energy Flow From Sun to Plants to Animals
C6H12O6 +
6O2. Also
aerobic
respiration:
C6H12O6 +
6O2 -> 6CO2
+ 6H2O +
Energy Out”
class=”wp-i
mage-414
size-large”
width=”1024″
height=”600″
> Figure 8.1
Energy Flow
From Sun to
Plants to
Animals
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.
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 lots of 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.
458 | Introduction
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Introduction | 459
The Atom
Cells are the basic building blocks of life, but atoms are the basic
building blocks of all matter, living and nonliving. The structural
elements of an atom are protons (positively charged), neutrons (no
charge), and electrons (negatively charged). Protons and neutrons
are contained in the dense nucleus of the atom; the nucleus thus has
a positive charge. Because opposites attract, electrons are attracted
to this nucleus and move around it in the electron cloud.
Electrons contain energy, and this energy is stored within the
charge and movement of electrons and the bonds atoms make with
one another. However, this energy is not always stable, depending
on the number of electrons within an atom. Atoms are more stable
when their electrons orbit in pairs. An atom with an odd number
of electrons must have an unpaired electron. In most cases, these
unpaired electrons are used to create chemical bonds. A chemical
bond is the attractive force between atoms and contains potential
energy. By bonding, electrons find pairs and chemicals become part
of a molecule.
Bond formation and bond breaking are chemical reactions that
involve the movement of electrons between atoms. These chemical
reactions occur continuously in the body. We previously reviewed
how glucose breaks down into water and carbon dioxide as part of
cellular respiration. The energy released by breaking those bonds
is used to form molecules of adenosine triphosphate (ATP). Recall
how during this process electrons are extracted from glucose in a
stepwise manner and transferred to other molecules. Occasionally
electrons “escape” and, instead of completing the cellular
respiration cycle, are transferred to an oxygen molecule. Oxygen (a
molecule with two atoms) with one unpaired electron is known as
superoxide (Figure 8.2).
460 | The Atom

Atoms and molecules such as superoxide that have unpaired
electrons are called free radicals; those containing oxygen are more
specifically referred to as reactive oxygen species. The unpaired
electron in free radicals destabilizes them, making them highly
reactive. Other reactive oxygen species include hydrogen peroxide
and the hydroxyl radical.
Figure 8.2 Superoxide
Image by
DoSiDo / CC
BY-SA 3.0
A molecule with one unpaired electron, which makes it a free

radical.
The reactivity of free radicals is what poses a threat to
macromolecules such as DNA, RNA, proteins, and fatty acids. Free
radicals can cause chain reactions that ultimately damage cells.
For example, a superoxide molecule may react with a fatty acid
and steal one of its electrons. The fatty acid then becomes a free
radical that can react with another fatty acid nearby. As this chain
reaction continues, the permeability and fluidity of cell membranes
changes, proteins in cell membranes experience decreased activity,
and receptor proteins undergo changes in structure that either alter
or stop their function. If receptor proteins designed to react to
insulin levels undergo a structural change it can negatively affect
glucose uptake. Free radical reactions can continue unchecked
unless stopped by a defense mechanism.
The Atom | 461

Metabolism Overview
Metabolism is defined as the sum of all chemical reactions required

to support cellular function and hence the life of an organism.
Metabolism is either categorized as catabolism, referring to all
metabolic processes involved in molecule breakdown, or anabolism,
which includes all metabolic processes involved in building bigger
molecules. Generally, catabolic processes release energy and
anabolic processes consume energy. The overall goals of
metabolism are energy transfer and matter transport. Energy is
transformed from food macronutrients into cellular energy, which
is used to perform cellular work. Metabolism transforms the matter
of macronutrients into substances a cell can use to grow and
reproduce and also into waste products. For example, enzymes are
proteins and their job is to catalyze chemical reactions. Catalyze
means to speed-up a chemical reaction and reduce the energy
required to complete the chemical reaction, without the catalyst
being used up in the reaction. Without enzymes, chemical reactions
would not happen at a fast enough rate and would use up too
much energy for life to exist. A metabolic pathway is a series of
enzyme catalyzed reactions that transform the starting material
(known as a substrate) into intermediates, that are the substrates
for subsequent enzymatic reactions in the pathway, until, finally,
an end product is synthesized by the last enzymatic reaction in
the pathway. Some metabolic pathways are complex and involve
many enzymatic reactions, and others involve only a few chemical
reactions.
To ensure cellular efficiency, the metabolic pathways involved in
catabolism and anabolism are regulated in concert by energy status,
hormones, and substrate and end-product levels. The concerted
regulation of metabolic pathways prevents cells from inefficiently
building a molecule when it is already available. Just as it would be
inefficient to build a wall at the same time as it is being broken
462 | The Atom

down, it is not metabolically efficient for a cell to synthesize fatty
acids and break them down at the same time.
Catabolism of food molecules begins when food enters the mouth,
as the enzyme salivary amylase initiates the breakdown of the starch
in foods. The entire process of digestion converts the large
polymers in food to monomers that can be absorbed. Starches are
broken down to monosaccharides, lipids are broken down to fatty
acids, and proteins are broken down to amino acids. These
monomers are absorbed into the bloodstream either directly, as is
the case with monosaccharides and amino acids, or repackaged in
intestinal cells for transport by an indirect route through lymphatic
vessels, as is the case with most fatty acids and other fat-soluble
molecules.
Once absorbed, water-soluble nutrients first travel to the liver
which controls their passage into the blood that transports the
nutrients to cells throughout the body. The fat-soluble nutrients
gradually pass from the lymphatic vessels into blood flowing to body
cells. Cells requiring energy or building blocks take up the nutrients
from the blood and process them in either catabolic or anabolic
pathways. The organ systems of the body require fuel and building
blocks to perform the many functions of the body, such as digesting,
absorbing, breathing, pumping blood, transporting nutrients in and
wastes out, maintaining body temperature, and making new cells.
Figure 8.3 Cellular Metabolic Processes
Metabolic
pathways of
a cell
The Atom | 463

Energy metabolism refers more specifically to the metabolic
pathways that release or store energy. Some of these are catabolic
pathways, like glycolysis (the splitting of glucose), β-oxidation
(fatty-acid breakdown), and amino acid catabolism. Others are
anabolic pathways, and include those involved in storing excess
energy (such as glycogenesis), and synthesizing triglycerides
(lipogenesis). Table 8.1 “Metabolic Pathways” summarizes some of
the catabolic and anabolic pathways and their functions in energy
metabolism.
Table 8.1 Metabolic Pathways
Catabolic Anabolic
Function Function
Pathways Pathways
Synthesize
Glycolysis Glucose breakdown Gluconeogenesis
glucose
Glycogen Synthesize
Glycogenolysis Glycogenesis
breakdown glycogen
Fatty-acid Synthesize
β-oxidation Lipogenesis
breakdown triglycerides
Protein breakdown Protein Synthesize
Proteolysis
to amino acids synthesis proteins
Catabolism: The Breakdown
All cells are in tune to their energy balance. When energy levels are
high cells build molecules, and when energy levels are low catabolic
pathways are initiated to make energy. Glucose is the preferred
energy source by most tissues, but fatty acids and amino acids also
can be catabolized to release energy that can drive the formation
of ATP. ATP is a high energy molecule that can drive chemical
reactions that require energy. The catabolism of nutrients to release
energy can be separated into three stages, each containing
individual metabolic pathways. The three stages of nutrient
breakdown are the following:
464 | The Atom

• Stage 1. Glycolysis for glucose, β-oxidation for fatty acids, or
amino-acid catabolism
• Stage 2. Citric Acid Cycle (or Krebs cycle)
• Stage 3. Electron Transport Chain and ATP synthesis
Figure 8.4 ATP Production Pathway

“Aerobic
Production
Pathways” by
Boumphreyfr
/ CC BY-SA
3.0
The breakdown of glucose begins with glycolysis, which is a ten-

step metabolic pathway yielding two ATP per glucose molecule;
glycolysis takes place in the cytosol and does not require oxygen. In
addition to ATP, the end-products of glycolysis include two three-
carbon molecules, called pyruvate. Pyruvate can either be shuttled
to the citric acid cycle to make more ATP or follow an anabolic
pathway. If a cell is in negative-energy balance, pyruvate is
transported to the mitochondria where it first gets one of its
carbons chopped off, yielding acetyl-CoA. The breakdown of fatty
acids begins with the catabolic pathway, known as β-oxidation,
which takes place in the mitochondria. In this catabolic pathway,
four enzymatic steps sequentially remove two-carbon molecules
from long chains of fatty acids, yielding acetyl-CoA molecules. In the
case of amino acids, once the nitrogen is removed from the amino
acid the remaining carbon skeleton can be enzymatically converted
into acetyl-CoA or some other intermediate of the citric acid cycle.
Acetyl-CoA, a two-carbon molecule common to glucose, lipid, and
protein metabolism enters the second stage of energy metabolism,
the citric acid cycle.
In the citric acid cycle, acetyl-CoA is joined to a four-carbon
molecule. In this multistep pathway, two carbons are lost as two
The Atom | 465

molecules of carbon dioxide. The energy obtained from the
breaking of chemical bonds in the citric acid cycle is transformed
into two more ATP molecules (or equivalents thereof) and high
energy electrons that are carried by the molecules, nicotinamide
adenine dinucleotide (NADH) and flavin adenine dinucleotide
(FADH2). NADH and FADH2 carry the electrons to the inner
membrane in the mitochondria where the third stage of energy
release takes place, in what is called the electron transport chain. In
this metabolic pathway a sequential transfer of electrons between
multiple proteins occurs and ATP is synthesized. The entire process
of nutrient catabolism is chemically similar to burning, as carbon
and hydrogen atoms are combusted (oxidized) producing carbon
dioxide, water, and heat. However, the stepwise chemical reactions
in nutrient catabolism pathways slow the oxidation of carbon atoms
so that much of the energy is captured and not all transformed into
heat and light. Complete nutrient catabolism is between 30 and 40
percent efficient, and some of the energy is therefore released as
heat. Heat is a vital product of nutrient catabolism and is involved in
maintaining body temperature. If cells were too efficient at trapping
nutrient energy into ATP, humans would not last to the next meal, as
they would die of hypothermia (excessively low body temperature).
Anabolism: The Building
The energy released by catabolic pathways powers anabolic

pathways in the building of macromolecules such as the proteins
RNA and DNA, and even entire new cells and tissues. Anabolic
pathways are required to build new tissue, such as muscle, after
prolonged exercise or the remodeling of bone tissue, a process
involving both catabolic and anabolic pathways. Anabolic pathways
also build energy-storage molecules, such as Glycogen and
triglycerides. Intermediates in the catabolic pathways of energy
metabolism are sometimes diverted from ATP production and used
466 | The Atom

as building blocks instead. This happens when a cell is in positive-
energy balance. For example, the citric-acid-cycle intermediate,
α-ketoglutarate can be anabolically processed to the amino acids
glutamate or glutamine if they are required. The human body is
capable of synthesizing eleven of the twenty amino acids that make
up proteins. The metabolic pathways of amino acid synthesis are
all inhibited by the specific amino acid that is the end-product of a
given pathway. Thus, if a cell has enough glutamine it turns off its
synthesis.
Anabolic pathways are regulated by their end-products, but even
more so by the energy state of the cell. When there is ample energy,
bigger molecules, such as protein, RNA and DNA, will be built as
needed. Alternatively, when energy is insufficient, proteins and
other molecules will be destroyed and catabolized to release energy.
A dramatic example of this is seen in children with marasmus, a
form of advanced starvation. These children have severely
compromised bodily functions, often culminating in death by
infection. Children with marasmus are starving for calories and
protein, which are required to make energy and build
macromolecules. The negative-energy balance in children who have
marasmus results in the breakdown of muscle tissue and tissues of
other organs in the body’s attempt to survive. The large decrease
in muscle tissue makes children with marasmus look emaciated or
“muscle-wasted.”
Figure 8.5 Metabolic Pathway of Gluconeogenesis
The Atom | 467

In a much less severe example, a person is also in negative-energy
balance between meals. During this time, blood-glucose levels start
to drop. In order to restore blood-glucose levels to their normal
range, the anabolic pathway, called gluconeogenesis, is stimulated.
Gluconeogenesis is the process of building glucose molecules
mostly from certain amino acids and it occurs primarily in the liver
(Figure 8.5 “Metabolic Pathway of Gluconeogenesis”). The liver
exports the synthesized glucose into the blood for other tissues to
use.
468 | The Atom

Energy Storage
In contrast, in the “fed” state (when energy levels are high), extra
energy from nutrients will be stored. Glucose is stored mainly in
muscle and liver tissues. In these tissues it is stored as glycogen, a
highly branched macromolecule consisting of thousands of glucose
molecules held together by chemical bonds. The glucose molecules
are joined together by an anabolic pathway called glycogenesis.
For each molecule of glucose stored, one molecule of ATP is used.
Therefore, it costs energy to store energy. Glycogen levels do not
take long to reach their physiological limit and when this happens
excess glucose will be converted to fat. A cell in positive-energy
balance detects a high concentration of ATP as well as acetyl-CoA
produced by catabolic pathways. In response, the rate of catabolism
is slowed or shut off and the synthesis of fatty acids, which occurs
by an anabolic pathway called lipogenesis, is turned on. The newly
made fatty acids are transported to fat-storing cells called
adipocytes where they are stored as triglycerides. Fat is a better
alternative to glycogen for energy storage as it is more compact (per
unit of energy) and, unlike glycogen, the body does not store water
along with fat. Water weighs a significant amount, and increased
glycogen stores, which are accompanied by water, would
dramatically increase body weight. When the body is in positive-
energy balance, excess carbohydrates, lipids, and protein can all be
metabolized to fat.
The Atom | 469

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Weight Management
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“Obesogenic” is a word that has sprung up in the language of public

health professionals in the last two decades. The Centers for
Disease Control and Prevention (CDC) defines obesogenic as “an
environment that promotes increased food intake, non-healthful
1
foods, and physical inactivity.”
1. Obesogenic Environments. Center for Disease Control

and Prevention (CDC). https://www.cdc.gov/pcd/
472 | Weight Management

The CDC reports that in 2009 in the United States, 33 percent of
adults and 16 percent of children were obese, a doubling and tripling
of the numbers since 1980, respectively, while in Hawai‘i the obesity
rate was 23.8% in 2016 with 40.8% of those individuals being Native
2
Hawaiians.
The health consequences of too much body fat are numerous,
including increased risks for cardiovascular disease, Type 2
diabetes, and some cancers. The medical costs related to obesity
are well over one hundred billion dollars and in Hawai‘i, over $470
million is spent annually. On the individual level, people who are
obese spend $1,429 more per year for medical care than people of
healthy weight.
Numerous obesogenic agents that contribute to this immense
public health problem have become a part of everyday life in
American society. The fast food industry has been growing for
decades and continues to grow despite the latest economic slump.
In America today there are over twelve thousand McDonald’s
restaurants, while in 1960 there was one. Food portions have been
getting bigger since the 1960s, and in the 1990s North American
society experienced the “super-size” marketing boom, which still
endures. Between 1960 and 2000 more than 123 million vehicles
were added to the American society. Escalators, elevators, and
horizontal walkways now dominate shopping malls and office
buildings, factory work has become increasingly mechanized and
robotized, the typical American watches more than four hours of
television daily, and in many work places the only tools required
issues/2015/14_0559.htm. Published 2013. Accessed

September 22, 2017.
2. Hawaii State Obesity Data, Rates, and Trends. The State
of Obesity: Better Policies for a Healthier America.
https://stateofobesity.org/states/hi/. Published August
Weight Management | 473

to conduct work are a chair and a computer. The list of all the
societal obesogenic factors goes on and on. They are the result
of modernization, industrialization, and urbanization continuing on
without individuals, public health officials, or government
adequately addressing the concurrent rise in overweight and
obesity.
With obesity at epidemic proportions in America it is paramount
that policies be implemented or reinforced at all levels of society,
and include education, agriculture, industry, urban planning,
healthcare, and government. Reversing and stopping obesity are
two different things. The former will require much more societal
and individual change than the latter. The following are some ideas
for constructing an environment in America that promotes health
and confronts the obesity epidemic:
Individual Level
• Purchase less prepared foods and eat more whole foods.

• Decrease portion sizes when eating or serving food.
• Eat out less, and when you do eat out choose low-calorie
options.
• Walk or bike to work. If this is not feasible, walk while you are
at work.
• Take the stairs when you come upon them or better yet, seek
them out.
• Walk your neighborhood and know your surroundings. This
benefits both health and safety.
• Watch less television.
Community Level
• Request that your college/workplace provides more access to

healthy low-cost foods.
• Support changes in school lunch programs.
• Participate in cleaning up local green spaces and then enjoy
them during your leisure time.

• Patronize local farms and fruit-and-vegetable stands.
• Talk to your grocer and ask for better whole-food choices and
seafood at a decent price.
• Ask the restaurants you frequently go to, to serve more
nutritious food and to accurately display calories of menu
items.
National Level
• Support policies that increase the walkability of cities.

• Support national campaigns addressing obesity, such as
America on the Move.
• Support policies that support local farmers and the increased
access and affordability of healthy food.
Some scientists predict that the childhood obesity rate will reach
100 percent by 2044. It is critical for the nation’s health to change
our environment to one that promotes weight loss and/or weight
maintenance. However, action is needed on multiple fronts to
reverse the obesity epidemic trend within one generation.
In this section you will learn how to assess body weight and
fatness. You will also learn that it is not only society and
environment that play a role in body weight and fatness, but also
physiology, genetics, and behavior—and that all of them interact.
We will also discuss the health risks of being underweight and
overweight, learn evidence-based solutions to maintain body
weight at the individual level, and assess the current state of affairs
of combating the obesity epidemic in the United States.

Balancing Energy Input with Energy Output
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To Maintain Weight, Energy Intake Must Balance

Energy Output
Recall that the macronutrients you consume are either converted to

energy, stored, or used to synthesize macromolecules. A nutrient’s
metabolic path is dependent upon energy balance. When you are in
a positive energy balance the excess nutrient energy will be stored
or used to grow (e.g., during childhood, pregnancy, and wound
healing). When you are in negative energy balance you aren’t taking
in enough energy to meet your needs, so your body will need to use
its stores to provide energy. Energy balance is achieved when intake
of energy is equal to energy expended. Weight can be thought of as
a whole body estimate of energy balance; body weight is maintained
when the body is in energy balance, lost when it is in negative
energy balance, and gained when it is in positive energy balance.
In general, weight is a good predictor of energy balance, but many
other factors play a role in energy intake and energy expenditure.
Some of these factors are under your control and others are not. Let

us begin with the basics on how to estimate energy intake, energy
requirement, and energy output. Then we will consider the other
factors that play a role in maintaining energy balance and hence,
body weight.
Estimating Energy Requirement
To maintain body weight you have to balance the calories obtained

from food and beverages with the calories expended every day.
Here, we will discuss how to calculate your energy needs in
kilocalories per day so that you can determine whether your caloric
intake falls short, meets, or exceeds your energy needs. The
Institute of Medicine has devised a formula for calculating your
Estimated Energy Requirement (EER). It takes into account your
age, sex, weight, height, and physical activity level (PA). The EER is
a standardized mathematical prediction of a person’s daily energy
needs in kilocalories per day required to maintain weight. It is
calculated for those over 18 years of age via the following formulas:
Adult male: EER = 662 − [9.53 X age (y)] + PA X [15.91 X wt (kg) +
5.39.6 X ht (m)]
Adult female: EER = 354 − [6.91 x age (y)] + PA x [9.36 x wt (kg) +
726 x ht (m)]
Note: to convert pounds to kilograms, divide weight in pounds by
2.2. To convert feet to meters, divide height in feet by 3.3.
Estimating Caloric Intake
To begin your dietary assessment, go to MyPlate, which is available

on the US Department of Agriculture (USDA) website:
http://www.choosemyplate.gov/.

3
Table 8.3 Physical Activity (PA) Categories and Values
Men Women
Activity Level PA PA Description
Value Value
No physical activity
beyond that
Sedentary 1.00 1.00
required for
independent living
Equivalent to
Low 1.11 1.12 walking 1.5 to 3
miles per day
Equivalent to
Moderate 1.25 1.27 walking 3 to 10 miles
per day
Equivalent to
High 1.48 1.45 walking 10 or more
miles per day
These values only apply to
normal weight adults and not to
children or pregnant or lactating
women.
These values only apply to normal weight adults and not to children
or pregnant or lactating women.
The numbers within the equations for the EER were derived from
measurements taken from a group of people of the same sex and age
with similar body size and physical activity level. These standardized
formulas are then applied to individuals whose measurements have
not been taken, but who have similar characteristics, in order to
estimate their energy requirements. Thus, a person’s EER is, as
the name suggests, an estimate for an average person of similar
characteristics. EER values are different for children, pregnant or
3. Dietary Reference Intake Tables.Health Canada.

http://www.hc-sc.gc.ca/fn-an/nutrition/reference/
table/index-eng.php#eeer. Updated November 29, 2010.

lactating women, and for overweight and obese people. Also,
remember the EER is calculated based on weight maintenance, not
for weight loss or weight gain.
The 2015 Dietary Guidelines provides a table (Table 8.4 “Estimated
Daily Calorie Needs”) that gives the estimated daily calorie needs
for different age groups of males and females with various activity
levels. The Dietary Guidelines also states that while knowing the
number of calories you need each day is useful, it is also pertinent
to obtain your calories from nutrient-dense foods and consume
the various macronutrients in their Acceptable Macronutrient
Distribution Ranges (AMDRs) (Table 8.5 “Acceptable Macronutrient
Distribution Ranges”).
Table 8.4 Estimated Daily Calorie Needs
Age
Sex Sedentary Moderately Active Active
(years)
Child 1,000–1,400
(female and 2–3 1,000 (male)1,000-1,200 1,000–1,400
male) (female)
Female 4–8 1,200–1,400 1,400–1,600 1,400–1,800

Female 9–13 1,400–1,600 1,600–2,000 1,800–2,200
Female 14–18 1,800 2,000 2,400
Female 19–30 1,800–2,000 2,000–2,200 2,400
Female 31–50 1,800 2,000 2,200

Female 51+ 1,600 1,800 2,000–2,200
Male 4–8 1,200–1,400 1,400–1,600 1,600–2,000
Male 9–13 1,600–2,000 1,800–2,200 2,000–2,600

Male 14–18 2,000–2,400 2,400–2,800 2,800–3,200
Male 19–30 2,400–2,600 2,600–2,800 3,000

Male 31–50 2,200–2,400 2,400–2,600 2,800–3,000
Male 51+ 2,000–2,200 2,200–2,400 2,400–2,800
Source: 2010 Dietary Guidelines for Americans. US Department of

Agriculture. http://health.gov/dietaryguidelines/dga2010/

DietaryGuidelines2010.pdf. Published 2010. Accessed September 22,
2017.
Table 8.5 Acceptable Macronutrient Distribution Ranges
Carbohydrates (% Protein (% of Fat (% of

Age
of Calories) Calories) Calories)
Young Children (1–3) 45–65 5–20 30–40

Older children/
45–65 10–30 25–35
adolescents (4–18)
Adults (19 and older) 45–65 10–35 20–35
Source: Dietary Reference Intakes: Macronutrients.” Dietary

Reference Intakes for Energy, Carbohydrate. Fiber, Fat, Fatty Acids,
Cholesterol, Protein, and Amino Acids. Institute of Medicine.
http://nationalacademies.org/hmd/~/media/Files/
Activity%20Files/Nutrition/DRI-Tables/
8_Macronutrient%20Summary.pdf?la=en. Accessed September 22,
2017.
Total Energy Expenditure (Output)
The amount of energy you expend every day includes not only the
calories you burn during physical activity, but also the calories you
burn while at rest (basal metabolism), and the calories you burn
when you digest food. The sum of caloric expenditure is referred
to as total energy expenditure (TEE). Basal metabolism refers to
those metabolic pathways necessary to support and maintain the
body’s basic functions (e.g. breathing, heartbeat, liver and kidney
function) while at rest. The basal metabolic rate (BMR) is the amount
of energy required by the body to conduct its basic functions over
a certain time period. The great majority of energy expended
(between 50 and 70 percent) daily is from conducting life’s basic
processes. Of all the organs, the liver requires the most energy

(Table 8.6 “Energy Breakdown of Organs”). Unfortunately, you
cannot tell your liver to ramp up its activity level to expend more
energy so you can lose weight. BMR is dependent on body size,
body composition, sex, age, nutritional status, and genetics. People
with a larger frame size have a higher BMR simply because they
have more mass. Muscle tissue burns more calories than fat tissue
even while at rest and thus the more muscle mass a person has, the
higher their BMR. Since females typically have less muscle mass and
a smaller frame size than men, their BMRs are generally lower than
men’s. As we get older muscle mass declines and thus so does BMR.
Nutritional status also affects basal metabolism. Caloric restriction,
as occurs while dieting, for example, causes a decline in BMR. This is
because the body attempts to maintain homeostasis and will adapt
by slowing down its basic functions to offset the decrease in energy
intake. Body temperature and thyroid hormone levels are additional
determinants of BMR.
Table 8.6 Energy Breakdown of Organs
Organ Percent of Energy Expended

Liver 27
Brain 19
Heart 7
Kidneys 10
Skeletal muscle (at rest) 18
Other organs 19
FAO/WHO/UNU, 1985.
Energy and Protein Requirements. World Health Organization
Technical Report Series 724. http://www.fao.org/doCReP/003/
aa040e/AA040E00.htm. Updated 1991. Accessed September 17, 2017.
Figure 8.6 Total Energy Expenditure

Total energy expenditure is the sum of energy expended at rest,
during digestion, and during physical activity.
The energy required for all the enzymatic reactions that take
place during food digestion and absorption of nutrients is called
the “thermic effect of food” and accounts for about 10 percent of
total energy expended per day. The other energy required during
the day is for physical activity. Depending on lifestyle, the energy
required for this ranges between 15 and 30 percent of total energy
expended. The main control a person has over TEE is to increase
physical activity.
How to Calculate Total Energy Expenditure
Calculating TEE can be tedious, but has been made easier as there
are now calculators available on the Web. TEE is dependent on
age, sex, height, weight, and physical activity level. The equations
are based on standardized formulas produced from actual
measurements on groups of people with similar characteristics. To
get accurate results from web-based TEE calculators, it is necessary
to record your daily activities and the time spent performing them.
A spreadsheet for doing so is available online at http://www.health-
calc.com/Calculate_daily_energy_expenditure.pdf. Health-
calc.com offers an interactive TEE
calculator. http://www.health-calc.com/diet/energy-
expenditure-advanced

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Factors Affecting Energy
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Physiology
In the last few decades scientific studies have revealed that how
much we eat and what we eat is controlled not only by our own
desires, but also is regulated physiologically and influenced by
genetics. The hypothalamus in the brain is the main control point of
appetite. It receives hormonal and neural signals, which determine
if you feel hungry or full. Hunger is an unpleasant sensation of
feeling empty that is communicated to the brain by both mechanical
and chemical signals from the periphery. Conversely, satiety is the
sensation of feeling full and it also is determined by mechanical
and chemical signals relayed from the periphery. The hypothalamus
Factors Affecting Energy Intake | 485

contains distinct centers of neural circuits that regulate hunger and
satiety (Figure 8.7).
Figure 8.7 Sagittal View of the Brain
Hypothalam
us by
Methoxyroxy
~commonswi
ki / Public
Domain
This is a scan of a brain. The hypothalamus contains distinct centers

of neural circuits that regulate hunger and satiety.
Hunger pangs are real and so is a “growling” stomach. When the
stomach is empty it contracts, producing the characteristic pang
and “growl.” The stomach’s mechanical movements relay neural
signals to the hypothalamus, which relays other neural signals to
parts of the brain. This results in the conscious feeling of the need
to eat. Alternatively, after you eat a meal the stomach stretches and
sends a neural signal to the brain stimulating the sensation of satiety
and relaying the message to stop eating. The stomach also sends out
certain hormones when it is full and others when it is empty. These
hormones communicate to the hypothalamus and other areas of the
brain either to stop eating or to find some food.
Fat tissue also plays a role in regulating food intake. Fat tissue
produces the hormone leptin, which communicates to the satiety
center in the hypothalamus that the body is in positive energy
486 | Factors Affecting Energy Intake

balance. The discovery of leptin’s functions sparked a craze in the
research world and the diet pill industry, as it was hypothesized that
if you give leptin to a person who is overweight, they will decrease
their food intake. Alas, this is not the case. In several clinical trials
it was found that people who are overweight or obese are actually
resistant to the hormone, meaning their brain does not respond as
1
well to it.
Therefore, when you administer leptin to an overweight or obese
person there is no sustained effect on food intake.
Nutrients themselves also play a role in influencing food intake.
The hypothalamus senses nutrient levels in the blood. When they
are low the hunger center is stimulated, and when they are high
the satiety center is stimulated. Furthermore, cravings for salty
and sweet foods have an underlying physiological basis. Both
undernutrition and overnutrition affect hormone levels and the
neural circuitry controlling appetite, which makes losing or gaining
weight a substantial physiological hurdle.
Genetic Influences
Genetics certainly play a role in body fatness and weight and also
affects food intake. Children who have been adopted typically are
similar in weight and body fatness to their biological parents.
Moreover, identical twins are twice as likely to be of similar weights
1. Dardeno TA, Chou, SH, et al.(2010). Leptin in Human

Physiology and Therapeutics. Frontiers in
Endocrinology, 31(3), 377–93.
2017.

as compared to fraternal twins. The scientific search for obesity
genes is ongoing and a few have been identified, such as the gene
that encodes for leptin. However, overweight and obesity that
manifests in millions of people is not likely to be attributed to one
or even a few genes, but the interactions of hundreds of genes
with the environment. In fact, when an individual has a mutated
version of the gene coding for leptin, they are obese, but only a
few dozen people around the world have been identified as having a
completely defective leptin gene.
Psychological/Behavioral Influences
When your mouth waters in response to the smell of a roasting

Thanksgiving turkey and steaming hot pies, you are experiencing
a psychological influence on food intake. A person’s perception of
good-smelling and good-tasting food influences what they eat and
how much they eat. Mood and emotions are associated with food
intake. Depression, low self-esteem, compulsive disorders, and
emotional trauma are sometimes linked with increased food intake
and obesity.
Certain behaviors can be predictive of how much a person eats.
Some of these are how much food a person heaps onto their plate,
how often they snack on calorie-dense, salty foods, how often they
watch television or sit at a computer, and how often they eat out. A
study published in a 2008 issue of Obesity looked at characteristics
of Chinese buffet patrons. The study found that those who chose to
immediately eat before browsing the buffet used larger plates, used
a fork rather than chopsticks, chewed less per bite of food, and had
2
higher BMIs than patrons who did not exhibit these behaviors.
2. Levin BE. (2010). Developmental Gene X Environment

Interactions Affecting Systems Regulating Energy

Of course many behaviors are reflective of what we have easy
access to—a concept we will discuss next.
Societal Influences
It is without a doubt that the American society affects what and

how much we eat. Portion sizes have increased dramatically in the
past few decades. For example, a bagel is now more than twice the
size it was in the 1960s. Today, American teenagers have access
to a massive amount of calorie-dense foods and beverages, which
is a large contributor to the recent rapid increase in overweight
and obesity in adolescents in this country. Even different cultures
within the United States have different eating habits. For instance,
Native Hawaiians and Pacific Islanders who have since adopted the
western diet, post-colonization consume foods high in fat, which is
a contributing factor to their higher incidences of overweight and
obesity.
The fast food industry in America not only supplies Americans
with a large proportion of their diet, but because of its massive
presence in society dominates the workings of the entire food
system. To generalize, most fast food items have little nutritional
merit as they are highly processed and rich in saturated fat, salt,
and added sugars. Despite fast foods being a poor source of
nourishment, Americans spend over one hundred billion dollars per
year on fast food, up from six billion dollars in the early 1970s. The
fast food business is likely to continue to grow in North America
Homeostasis and Obesity. Frontiers in Endocrinology, 3,

2017.

(and the rest of the world) and greatly affect the diets of whole
populations. Because it is unrealistic to say that Americans should
abruptly quit eating fast food to save their health (because they will
not) society needs to come up with ideas that push nutrient-dense
whole foods into the fast food industry. You may have observed
that this largely consumer-driven push is having some effect on the
foods the fast food industry serves (just watch a recent Subway
commercial, or check the options now available in a McDonald’s
Happy Meal). Pushing the fast food industry to serve healthier foods
is a realistic and positive way to improve the American diet.
Tools for Change
Support the consumer movement of pushing the fast food industry

and your favorite local restaurants into serving more nutrient-
dense foods. You can begin this task by starting simple, such as
requesting extra tomatoes and lettuce on your burger and more
nutrient-dense choices in the salad bar. Also, choose their low-
calorie menu options and help support the emerging market of
healthier choices in the fast food industry. In today’s fast-paced
society, it is difficult for most people to avoid fast food all the time.
When you do need a quick bite on the run, choose the fast food
restaurants that serve healthier foods. Also, start asking for caloric
contents of foods so that the restaurant becomes more aware that
their patrons are being calorie conscious.

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Physiological and Genetic Influences
Why is it so difficult for some people to lose weight and for others
to gain weight? One theory is that every person has a “set point”
of energy balance. This set point can also be called a fat-stat or
lipostat, meaning the brain senses body fatness and triggers
changes in energy intake or expenditure to maintain body fatness
within a target range. Some believe that this theory provides an
explanation as to why after dieting, most people return to their
original weight not long after stopping the diet. Another theory is
referred to as the “settling” point system, which takes into account
(more so than the “set-point” theory) the contribution of the
obesogenic environment to weight gain. In this model, the reservoir
492 | Factors Affecting Energy

Expenditure
of body fatness responds to energy intake or energy expenditure,
such that if a person is exposed to a greater amount of food, body
fatness increases, or if a person watches more television body
fatness increases. A major problem with these theories is that they
overgeneralize and do not take into account that not all individuals
respond in the same way to changes in food intake or energy
expenditure. This brings up the importance of the interactions of
genes and the environment.
Not all individuals who take a weight-loss drug lose weight and
not all people who smoke are thin. An explanation for these
discrepancies is that each individual’s genes respond differently
to a specific environment. Alternatively, environmental factors can
influence a person’s gene profile, which is exemplified by the effects
of the prenatal environment on body weight and fatness and disease
1
incidence later in life.
One example is a study of the offspring of women who were
overweight during pregnancy had a greater propensity for being
overweight and for developing Type 2 diabetes. Thus,
undernutrition and overnutrition during pregnancy influence body
weight and disease risk for offspring later in life. They do so by
adapting energy metabolism to the early nutrient and hormonal
environment in the womb.
1. Matthews CE, Chen KY, et al. (2008). Amount of Time

Spent in Sedentary Behaviors in the United States,
2003–2004. American Journal of Epidemiology, 167(7),
Factors Affecting Energy Expenditure | 493

Psychological/Behavioral Influence
Sedentary behavior is defined as the participation in the pursuits in

which energy expenditure is no more than one-and-one-half times
the amount of energy expended while at rest and include sitting,
reclining, or lying down while awake. Of course, the sedentary
lifestyle of many North Americans contributes to their average
energy expenditure in daily life. Simply put, the more you sit, the
less energy you expend. A study published in a 2008 issue of the
American Journal of Epidemiology reports that 55 percent of
2
Americans spend 7.7 hours in sedentary behavior daily.
Fortunately, including only a small amount of low-level physical
activity benefits weight control. A study published in the June 2001
issue of the International Journal of Behavioral Nutritionand
Physical Activity reports that even breaking up sitting-time with
frequent but brief increased energy expenditure activities, such as
walking for five minutes every hour, helps maintain weight and even
3
aids in weight loss.
Americans partake in an excessive amount of screen time, which
is a sedentary behavior that not only reduces energy expenditure,
but also contributes to weight gain because of the exposure to
aggressive advertising campaigns for unhealthy foods.
2. Matthews CE, Chen KY, et al. (2008). Amount of Time

Spent in Sedentary Behaviors in the United States,
2003–2004. American Journal of Epidemiology, 167(7),
3. Wu Y. (2006). Overweight and Obesity in China. British
Medical Journal, 333(7564), 362-363.
494 | Factors Affecting Energy Expenditure

Societal Influence
In the United States, many societal factors influence the number of

calories burned in a day. Escalators, moving walkways, and elevators
(not to mention cars!) are common modes of transportation that
reduce average daily energy expenditure. Office work, high-stress
jobs, and occupations requiring extended working hours are all
societal pressures that reduce the time allotted for exercise of large
populations of Americans. Even the remote controls that many have
for various electronic devices in their homes contribute to the US
society being less active. More obesogenic factors were discussed in
the weight management section of this chapter.
Socioeconomic status has been found to be inversely proportional
to weight gain. One reason for this relationship is that inhabitants
of low-income neighborhoods have reduced access to safe streets
and parks for walking. Another is that fitness clubs are expensive
and few are found in lower-income neighborhoods. The recent and
long-lasting economic crisis in this country is predicted to have
profound effects on the average body weight of Americans. The
number of homeless in this country is rising with many children and
adults living in hotels and cars. As you can imagine neither of these
“home spaces” has a kitchen, making it impossible to cook nutritious
meals and resulting in increased economically-forced access to
cheap, unhealthy foods, such as that at a nearby gas station.
Too Little or Too Much Weight: What Are the

Health Risks?
The number of people considered overweight and obese in the

world has now surpassed the number that are starving, with some
officials estimating that the number of overweight people is nearly
double the number of underweight people worldwide. Countries

that have more recently modernized, industrialized, and urbanized
are experiencing a surge in their overweight and obese populations.
China, the most populous country in the world, now has more than
215 million people, approximately one-fifth of their population, that
4
are considered overweight or obese.
The increase in China’s waistline is partly attributed to changes
in the traditional diet, more sedentary lives, and a massive increase
in motor vehicle use. Moreover, China’s recent famines in the 1950s,
which affected the poor and lower classes to a greater extent than
the upper class, have sanctioned lax social attitudes toward body
fat and reinspired the age-old Chinese belief that excess body fat
represents health and prosperity.
One of the worst statistics regarding overweight and obesity in
China is that more than ten million adolescents between ages
seventeen and eighteen were overweight in 2000, which is twenty-
5
eight times the number that were overweight in 1985.
The associated diseases of overweight and obesity happen over
many years, and signs and symptoms commonly take decades to
manifest. With China’s younger population and other developed
countries experiencing a dramatic weight increase, the associated
chronic diseases will come about much earlier in life than in
previous generations. This will put an even greater burden on
society.

Medical Journal, 333(7564), 362-363.
Medical Journal, 333(7564), 362-363.

Health Risks of Being Overweight and Being
Obese
The health consequences of obesity are great and contribute to

more than one hundred thousand deaths per year in the United
6
States. According to the CDC, in the United States in 2013-2014 :
• 37.9% of adults age twenty years and over were obese

• 70.7% of adults age twenty years and over were overweight,
including obese
• 20.6% of adolescents age twelve to nineteen years were obese
• 17.4% of children age six to eleven years were obese
• 9.4% of children age two to five years were obese
6. Obesity and Overweight.The Centers for Disease Control

and Prevention. https://www.cdc.gov/nchs/fastats/
obesity-overweight.htm. Updated May 3, 2017. Accessed
June 19, 2017.

State Map of the Prevalence of Obesity
in America
US state
map of
obesity
prevalence
https://w
ww.cdc.go
v/obesity/
data/
prevalence
-maps.ht
ml
Visit https://www.cdc.gov/obesity/data/prevalence-
maps.html to see the prevalence of self-reported obesity
among U.S. adults from 2014-2016.
As BMIs increase over 25, the risks increase for heart disease,
Type 2 diabetes, hypertension, endometrial cancer, postmenopausal
breast cancer, colon cancer, stroke, osteoarthritis, liver disease,
gallbladder disorders, and hormonal disorders. The WHO reports
that overweight and obesity are the fifth leading cause for deaths
globally, and estimates that more than 2.8 million adults die annually

7
as a result of being overweight or obese. Moreover, overweight and
obesity contribute to 44 percent of the Type 2 diabetes burden, 23
percent of the heart disease burden, and between 7 and 41 percent
8
of the burden of certain cancers.
Similar to other public health organizations, the WHO states the
main causes of the obesity epidemic worldwide are the increased
intake of energy-dense food and decreased level of physical activity
that is mainly associated with modernization, industrialization, and
urbanization. The environmental changes that contribute to the
dietary and physical activity patterns of the world today are
associated with the lack of policies that address the obesity
epidemic in the food and health industry, urban planning,
agriculture, and education sectors.
Learning Activities

7. Obesity and Overweight. World Health Organization.

http://www.who.int/mediacentre/factsheets/fs311/
en/. Updated June 2016. Accessed September 22, 2017.
8. Obesity and Overweight. World Health Organization.
en/. Updated June 2016. Accessed September 22, 2017.

Open Document).



Dietary, Behavioral, and
Physical Activity
Recommendations for Weight
Management
Photo by Igor
Ovsyannikov
on
unsplash.co
m / CC0
We have just considered the gravity of the obesity problem in

America and worldwide. How is America combating its weight
problem on a national level, and have the approaches been
successful? Successful weight loss is defined as individuals
intentionally losing at least 10 percent of their body weight and
Dietary, Behavioral, and Physical

Activity Recommendations for Weight
1
keeping it off for at least one year. Results from lifestyle
intervention studies suggest fewer than 20 percent of participants
are successful at weight loss. An evaluation of successful weight
loss, involving more than fourteen thousand participants published
in the November 2011 issue of the International Journal of Obesity
estimates that more than one in six Americans (17 percent) who
were overweight or obese were successful in achieving long-term
2
weight loss. However, these numbers are on the high end because
many similar studies report fewer than 10 percent of participants as
successful in weight loss.
The National Weight Control Registry (NWCR) tracks over ten
thousand people who have been successful in losing at least 30
pounds and maintaining this weight loss for at least one year. Their
research findings are that 98 percent of participants in the registry
modified their food intake and 94 percent increased their physical
3
activity (mainly walking).
Although there are a great variety of approaches taken by NWCR
members to achieve successful weight loss, most report that their
approach involved adhering to a low-calorie, low-fat diet and doing
1. Wing RR, Hill JO. (2001). Successful Weight Loss

Maintenance. Annual Review of Nutrition, 21, 323–41.
http://www.ncbi.nlm.nih.gov/pubmed/
11375440?dopt=Abstract. Accessed September 22, 2017.
2. Kraschnewski JL, Boan J, et al. (2010). Long-Term Weight
Loss Maintenance in the United States. International
Journal of Obesity, 34(11),1644–54.
3. Research Findings. The National Weight Control
Registry. http://www.nwcr.ws/Research/default.htm.
502 | Dietary, Behavioral, and Physical Activity Recommendations for
Weight Management
high levels of activity (about one hour of exercise per day).
Moreover, most members eat breakfast every day, watch fewer than
ten hours of television per week, and weigh themselves at least once
per week. About half of them lost weight on their own, and the
other half used some type of weight-loss program. In most scientific
studies successful weight loss is accomplished only by changing the
diet and by increasing physical activity. Doing one without the other
limits the amount of weight lost and the length of time that weight
loss is sustained. On an individual level it is quite possible to achieve
successful weight loss, as over ten thousand Americans can attest.
Moreover, losing as little as 10 percent of your body weight can
4
significantly improve health and reduce disease risk.
You do not have to be overweight or obese to reap benefits from
eating a healthier diet and increasing physical activity as both
provide numerous benefits beyond weight loss and maintenance.
Evidence-Based Dietary Recommendations
The 2015 Dietary Guidelines for Americans offers specific,

evidence-based recommendations for dietary changes aimed at
keeping calorie intake in balance with physical activity, which is key
for weight management. These recommendations include:
Follow a healthy eating pattern that accounts for all foods and
beverages within an appropriate calorie level that includes:
4. Clinical Guidelines on the Identification, Evaluation, and

Treatment of Overweight and Obesity in Adults: The
Evidence Report. National Heart, Lung, and Blood
Institute. 1998, 51S–210S. http://www.ncbi.nlm.nih.gov/
books/NBK2003/. Accessed September 22, 2017.
Dietary, Behavioral, and Physical Activity Recommendations for Weight
Management | 503
• 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
A healthy eating pattern limits:
• Saturated fats and trans fats

• Added sugars
• Sodium
Key quantitative recommendations are provided for several

components of the diet that should be limited. These components
are of particular public health concern in the United States, and the
specified limits can help individuals achieve healthy eating patterns
5
within calorie limits :
• 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
5. 2010 Dietary Guidelines for Americans. US Department

of Agriculture. http://health.gov/dietaryguidelines/
dga2010/DietaryGuidelines 2010.pdf. Published 2010.
Weight Management
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.
Evidence-Based Physical Activity

Recommendations
The other part of the energy balance equation is physical activity.

The Dietary Guidelines are complemented by the 2008 Physical
Activity Guidelines for Americans issued by the Department of
Health and Human Services (HHS) in an effort to provide evidence-
based guidelines for appropriate physical activity levels. The 2008
Physical Activity Guidelines provide guidance to Americans aged
six and older about how to improve health and reduce chronic
disease risk through physical activity. Increased physical activity has
been found in scientific studies to lower the risk of heart disease,
stroke, high blood pressure, Type 2 diabetes, colon, breast, and lung
cancer, falls and fractures, depression, and early death. Increased
physical activity not only reduces disease risk, but also improves
overall health by increasing cardiovascular and muscular fitness,
increasing bone density and strength, improving cognitive function,
6
and assisting in weight loss and weight maintenance.
The key guidelines for adults are the following (those for pregnant
women, children, and older people will be given in Chapter 13):
6. 2008 Physical Activity Guidelines for Americans. US

Department of Health and Human Services.
http://www.health.gov/paguidelines/guidelines/
chapter2.aspx. Published 2008. Accessed September 22,
2017.
Management | 505
• Even small amounts of activity are beneficial to your health.
• More substantial health benefits are obtained by doing at least
two hours and thirty minutes per week of moderate-intensity,
or one hour and fifteen minutes per week of vigorous-intensity
aerobic physical activity, or an equivalent combination thereof.
Aerobic activity has better benefits if performed for at least ten
minutes at a time, spread throughout the week.
• More extensive health benefits occur when moderate-intensity
physical activity is increased to five hours per week, or to two
hours and thirty minutes of vigorous-intensity aerobic physical
activity, or a combination thereof. Additional health benefits
are gained by going beyond these recommended amounts of
physical activity.
• Muscle-strengthening activities at moderate or high intensity
involving all major muscle groups two or more days per week
provides additional health benefits to aerobic exercise.
The 2008 Physical Activity Guidelines broadly classify moderate

physical activities as those when “you can talk while you do them,
but can’t sing” and vigorous activities as those when “you can only
7
say a few words without stopping to catch your breath.”
8
Table 8.7 Moderate and Vigorous Physical Activities

2017.
8. Source: 2008 Physical Activity Guidelines for Americans.
US Department of Health and Human Services.
Weight Management
Moderate Activities Vigorous Activities
Ballroom/line dancing Aerobic dance

Biking on level ground Biking (more than 10 miles per hour)
Canoeing Heavy gardening (digging, hoeing)
Gardening Hiking uphill

Baseball, softball, volleyball Fast dancing
Campaigns for a Healthy-Weight America
On a national level, strategies addressing overweight and obesity in

the past have not been all that successful, as obesity levels continue
to climb. However, in the recent past (2007–2011) several newly
created initiatives and organizations are actively reinforcing
strategies aimed to meet the challenge of improving the health of all
Americans.
In 2010 the national campaign to reduce obesity was reinforced
when First Lady Michelle Obama launched the “Let’s Move”
initiative, which has the goal of “solving the challenge of childhood
obesity within a generation so that children born today will reach
9
adulthood at a healthy weight.” Another campaign, “Campaign to
End Obesity,” was recently established to try to enable more

2017.
9. The White House, Office of the First Lady. First Lady
Michelle Obama Launches Let’s Move: America’s Move to
Raise a Healthier Generation of
Kids.https://letsmove.obamawhitehouse.archives.gov/
about. Published February 9, 2010. Accessed September
22, 2017.
Management | 507
Americans to eat healthy and be active by bringing together leaders
from academia and industry, as well as public-health policy-makers
in order to create policies that will reverse the obesity trend and its
associated diseases.
The “Small-Change” Approach
Currently, most people are not obese in this country. The gradual
rise in overweight is happening because, on average, people
consume slightly more calories daily than they expend, resulting in
a gradual weight gain of one to two pounds a year. In 2003 the idea
was first published that promoting small lifestyle changes to reduce
weight gain occurring over time in all age groups may better reduce
10
obesity rates in the American population.
Scientific studies have demonstrated that asking people to
increase the number of steps they take each day while providing
them with pedometers that count the steps they take each day
successfully prevented weight gain. A “small-changes” study
published in the October 2007 issue of Pediatrics evaluated whether
families that made two small lifestyle changes, which were to walk
an additional two thousand steps per day and to eliminate 100
kilocalories per day from their typical diet by replacing dietary sugar
with a noncaloric sweetener, would prevent weight gain in
10. Hill JO. (2009). Can a Small-Changes Approach Help

Address the Obesity Epidemic? A Report of the Joint
Task Force of the American Society for Nutrition,
Institute of Food Technologists, and International Food
Information Council. American Journal of Clinical
Nutrition, 89(2), 477–84. http://www.ajcn.org/content/
89/2/477.long. Accessed September 22, 2017.
Weight Management
11
overweight children. The results of this study were that a higher
percentage of children who made the small changes maintained or
reduced their BMI in comparison to children of families given a
pedometer but not asked to also make physical activity or dietary
12
changes. Several more studies funded by the National Institutes of
Health and USDA are ongoing and are evaluating the effectiveness
of the “small-changes” approach in reducing weight gain.
In 2009, a report of the Joint Task Force of the American Society
for Nutrition, Institute of Food Technologists, and International
Food Information Council proposed that the “small-changes”
approach when supported at the community, industry, and
governmental levels will be more effective than current strategies in
13
gradually reducing the obesity rate in America.
11. Rodearmel SJ, Wyatt HR, et al. (2007). Small Changes in

Dietary Sugar and Physical Activity As an Approach to
Preventing Excessive Weight Gain: The America on the
Move Family Study. Pediatrics, 120(4), e869–79.
http://pediatrics.aappublications.org/content/120/4/
e869.long. Accessed September 22, 2017.
12. Rodearmel SJ, Wyatt HR, et al. (2007). Small Changes in
Dietary Sugar and Physical Activity As an Approach to
Preventing Excessive Weight Gain: The America on the
Move Family Study. Pediatrics, 120(4), e869–79.
http://pediatrics.aappublications.org/content/120/4/
e869.long. Accessed September 22, 2017.
13. Hill JO. (2009). Can a Small-Changes Approach Help
Address the Obesity Epidemic? A Report of the Joint
Task Force of the American Society for Nutrition,
Institute of Food Technologists, and International Food
Information Council. American Journal of Clinical
Management | 509
The HHS encouraged the approach and launched a “Small Step”
website in 2008.
Learning Activities

Open Document).


Nutrition, 89(2), 477–84. http://www.ajcn.org/content/

89/2/477.long. Accessed September 22, 2017.
Weight Management


Management | 511
PART IX
CHAPTER 9. VITAMINS
Chapter 9. Vitamins | 513

Introduction
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
Introduction | 515
Learning Objectives
• 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
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
1
percent .
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.
516 | Introduction
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 http://www.islandfood.org/
and watch the video at https://www.youtube.com/
watch?v=DGVxnefqbTQ.
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.
Figure 9.1 The Vitamins
Image by
Allison
Calabrese /
CC BY 4.0
Accessed October 15, 2017.
Introduction | 517
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.
Figure 9.2 “Absorption of Fat-Soluble and Water-Soluble Vitamins
Image by
Allison
Calabrese /
CC BY 4.0
518 | Introduction
Learning Activities

Open Document).


Introduction | 519
520 | Introduction
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
Fat-Soluble Vitamins | 521

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.
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
spots), causing dryness of the eyes, a condition called
522 | Fat-Soluble Vitamins

xerophthalmia. The progression of this condition can cause
ulceration of the cornea and eventually blindness.
Figure 9.3 Bitot Spot caused by vitamin A deficiency
Malnutrition
-Bitot’s
Spots/
Bitot’s Spots
caused by
vitamin A
deficiency by
CDC /
Nutrition
Program
Figure 9.4 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
1
deaths annually.
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.
1. Sommer A. (2008). Vitamin A Deficiency and Clinical

Disease: An Historical Overview. Journal of Nutrition, 138,
1835.long. Accessed October 4, 2017.

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
2
was consequently stopped.
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.
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. http://jnci.oxfordjournals.org/
content/96/23/1743.long. Accessed October 6, 2017.

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
3
conversions are listed below :
• 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
3. Dietary Supplement Fact Sheet: Vitamin A. National

Institutes of Health, Office of Dietary Supplements.
http://ods.od.nih.gov/factsheets/VitaminA-
QuickFacts/. Updated September 5, 2012. Accessed
October 7, 2017.

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 9.1 Dietary Reference Intakes for Vitamin A
RDA Males and Females mcg RAE/

Age Group UL
day
Infants (0–6 months) 400* 600

Children (1–3 years) 300 600
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

http://ods.od.nih.gov/factsheets/VitaminA-QuickFacts/. Updated
September 5, 2012. Accessed October 7, 2017.
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 9.2 “Vitamin A Content of Various Foods”). The
dietary sources of carotenoids will be given in the following text.
Table 9.2 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

http://ods.od.nih.gov/factsheets/VitaminA-QuickFacts/. 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 9.3 “Alpha- and Beta-Carotene Content of
Various Foods” for the carotenoid content of various foods.
Table 9.3 Alpha- and Beta-Carotene Content of Various Foods
Beta-carotene Alpha-carotene
Food Serving
(mg) (mg)
Pumpkin, canned 1c. 17.00 11.70
Carrot juice 1c. 22.00 10.20

Carrots, cooked 1c. 13.00 5.90
1
Carrots, raw 5.10 2.10
medium
Winter squash,
1c. 5.70 1.40
baked
Collards, cooked 1c. 11.60 0.20

1
Tomato 0.55 0.10
medium
1
Tangerine 0.13 0.09
medium
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. http://www.ars.usda.gov/ba/bhnrc/ndl.
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.
Figure 9.5 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.
Figure 9.6 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

4
percent and other nonvertebral fractures by 23 percent. 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
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. http://jama.ama-
assn.org/content/293/18/2257.long. Accessed October
12, 2017.

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 10.4 “Dietary Reference Intakes for Vitamin
D”. 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 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 9.4 Dietary Reference Intakes for Vitamin D

Age Group RDA (mcg/day) UL (mcg/day)
Infant (0–6 months) 10* 25


Adolescents (14–18 years) 15 50
Adults (19–71 years) 15 50
Adults (> 71 years) 20 50
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. http://www.ncbi.nlm.nih.gov/pubmed/
Dietary Sources of Vitamin D
Table 9.5 Vitamin D Content of Various Foods

Vitamin Percent
Food Serving
D (IU) Daily Value
Swordfish 3 oz. 566 142
Salmon 3 oz. 447 112
Tuna fish, canned in water, drained 3 oz. 154 39
Orange juice fortified with vitamin D 1 c. 137 34
Milk, nonfat, reduced fat, and whole,
1 c. 115-124 29-31
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
Supplements.https://ods.od.nih.gov/factsheets/VitaminD-
HealthProfessional/#h3. Updated September 5, 2012. Accessed
October 22, 2017.
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
56
disease risk.
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.
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. https://www.ncbi.nlm.nih.gov/
pubmed/21683786. 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.

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
7
from all causes.
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
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. https://jamanetwork.com/journals/jama/
fullarticle/195531. Accessed October 5, 2017.

international units (264 milligrams) per day or 600 international
units (396 milligrams) every other day reduced the risk of
89
developing any form of cancer.
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.
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.
http://jama.ama-assn.org/content/293/11/1338.long.,
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. http://jama.ama-assn.org/
content/294/1/56.long. Accessed October 5, 2017.

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 with
the highest intakes of dietary vitamin E were 25 percent less likely
to develop dementia than those with the lowest intakes of vitamin
10
E.
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.
10. Devore EE, et al. (2010). Dietary Antioxidants and Long-

Term Risk of Dementia, Archives of Neurology, 67(7),
PMC2923546/?tool=pubmed. Accessed October 5, 2017.

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
11
causing an inhibition of blood clotting.
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 9.6 “Dietary Reference Intakes for Vitamin E”.
Table 9.6 Dietary Reference Intakes for Vitamin E
11. Dietary Supplement Fact Sheet: Vitamin E.National

http://ods.od.nih.gov/factsheets/VitaminE-
QuickFacts/. Updated October 11, 2011. Accessed
October 5, 2017.

Age Group RDA Males and Females mg/day UL
Infants (0–6 months) 4* –


Adults (> 19 years) 15 1,000
*denotes Adequate Intake
Source: Dietary Supplement Fact Sheet: Vitamin E.National

http://ods.od.nih.gov/factsheets/VitaminE-QuickFacts/. 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.

Image by
rawpixel.com
on
unsplash.co
m / 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 10.7 “Vitamin E Content of Various
Foods” 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 9.7 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 E.National

http://ods.od.nih.gov/factsheets/VitaminE-QuickFacts/. 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 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 9.8 Dietary Reference Intakes for Vitamin K

Age Group RDA (mcg/day)
Infants (0–6 months) 2.0*

Children (1–3 years) 30

Adolescents (14–18 years) 75
Adult Males (> 19 years) 120
Adult Females (> 19 years) 90
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.
http://www.iom.edu/Reports/2001/Dietary-Reference-Intakes-
for-Vitamin-A-Vitamin-K-Arsenic-Boron-Chromium-Copper-
Iodine-Iron-Manganese-Molybdenum-Nickel-Silicon-Vanadium-a
nd-Zinc.aspx. 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.
Table 9.9 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 9.10 Fat-Soluble Vitamins

Recommended Deficiency
Vitamin Sources Intake for Major functions diseases and
adults symptoms
Retinol: beef and Xerophthalmia,

chicken liver, night
Vitamin A
skim milk, whole Antioxidant,vision, blindness, eye
(retinol,
milk, cheddar cell infections;
retinal, 700-900
cheese; differentiation, poor growth,
retinoic mcg/day
Carotenoids: reproduction, dry skin,
acid,carotene,
pumpkin, carrots, immune function impaired
beta-carotene)
squash, collards, immune
peas function
Rickets in
Swordfish, children:
salmon, tuna, Absorption and abnormal
orange juice regulation of growth,
600-800 IU/
(fortified), milk calcium and misshapen
Vitamin D day (15-20
(fortified), phosphorus, bones, bowed
mcg/day)
sardines, egg, maintenance of legs, soft
synthesis from bone bones;
sunlight osteomalacia
in adults
Sunflower seeds, Antioxidant, Broken red

Vitamin E almonds, 15 mg/day protects cell blood cells,
hazelnuts,peanuts membranes nerve damage
Synthesis of blood
Vegetable oils, clotting proteins
leafy greens, 90-120 mcg/ and proteins
Vitamin K Hemorrhage
synthesis by day needed for bone
intestinal bacteria health and cell
growth

Learning Activities

Open Document).



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 9.7 Enzyme Active Site for Cofactors
550 | Water-Soluble Vitamins

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
Water-Soluble Vitamins | 551

holds the collagen fibers together and without sufficient levels in
the body, collagen strands are weak and abnormal. (Figure 9.8 “The
Role of Vitamin C in Collagen Synthesis”)
Figure 9.8 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 9.9 Bleeding Gums Associated with Scurvy
Scorbutic
gums due to
a vitamin C
deficiency, a
symptom of
scurvy.
https://com
mons.wikime
dia.org/
wiki/
File:Scorbuti
c_gums.jpg
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 intakes are
correlated with reduced cardiovascular disease risk, but there is
insufficient evidence to conclude that taking vitamin C supplements
1
influences cardiovascular disease risk. Vitamin C levels in the body
have been shown to correlate well with fruit and vegetable intake,
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. http://archinte.ama-assn.org/
cgi/content/full/169/7/659. Accessed October 5, 2017.

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
2
had a 42 percent decreased risk for having a stroke.
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
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.
http://www.ajcn.org/content/87/1/64.long. Accessed
September 22, 2017.

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
3
benefits.
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
3. Douglas RM, et al. (2004). Vitamin C for Preventing and

Treating the Common Cold. Cochrane Database of
Systematic Reviews, 4. http://www.ncbi.nlm.nih.gov/
pubmed/15495002?dopt=Abstract. Accessed October 5,
2017.

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 9.11 “Dietary Reference Intakes for Vitamin C”. 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 9.11 Dietary Reference Intakes for Vitamin C
Age Group RDA Males and Females mg/day UL


Adolescents (14–18 years) 75 (males), 65 (females) 1800
Adults (> 19 years) 90 (males), 75 (females) 2000
Source: Dietary Supplement Fact Sheet: Vitamin C. National

http://ods.od.nih.gov/factsheets/VitaminC-QuickFacts/. 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 “Vitamin C Content of Various Foods”.
Table 9.12 Vitamin C Content of Various Foods
Vitamin C Percent Daily

Food Serving
(mg) 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
½ c. raw 95 158
pepper
Broccoli ½ c. cooked 51 65
Romaine lettuce 2 c. 28 47
Cauliflower 1 c. boiled 55 86
1 medium,
Potato 17 28
baked
Source: Dietary Supplement Fact Sheet: Vitamin C. National

http://ods.od.nih.gov/factsheets/VitaminC-QuickFacts/. Updated

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 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
4
grow. 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-
4. Frederick Gowland Hopkins and his Accessory Food

Factors. Encyclopedia Brittanica Blog.
http://www.britannica.com/blogs/2011/06/frederick-
gowland-hopkins-accessory-food-factors/.Published

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
5
surgery.
Figure 9.10 The Role of Thiamin
Image by
Allison
Calabrese /
CC BY 4.0
Figure 9.11 Beriberi, Thiamin Deficiency
5. Fact Sheets for Health Professionals: Thiamin. National

Institute of Health, Office of Dietary Supplements.
https://ods.od.nih.gov/factsheets/Thiamin-
HealthProfessional/. Updated Feburary 11, 2016.

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 9.13 “Dietary Reference Intakes for Thiamin”. There is no UL
for thiamin because there has not been any reports on toxicity when
excess amounts are consumed from food or supplements.
Table 9.13 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

Adolescents (14–18 years) 1.2 (males), 1.0 (females)
Adults (> 19 years) 1.2 (males), 1.1 (females)
Health Professional Fact Sheet: Thiamin. National Institutes of

Health, Office of Dietary Supplements.https://ods.od.nih.gov/
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 “Thiamin Content of Various Foods”.
Table 9.14 Thiamin Content of Various Foods

Thiamin Percent Daily
Food Serving
(mg) Value
1
Breakfast cereals, fortified 1.5 100
serving
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 Supplements.https://ods.od.nih.gov/
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”
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.
The RDAs for different age groups for riboflavin are listed in Table
9.15 “Dietary Reference Intakes for Riboflavin”. There is no UL for
riboflavin because no toxicity has been reported when an excess
amount has been consumed through foods or supplements.
Table 9.15 Dietary Reference Intakes for Riboflavin
Age Group RDA Males and Females mg/day

Infants (0–6 months) 0.3 *


Adolescents (14–18 years) 1.3 (males), 1.0 (females)
Adults (> 19 years) 1.3 (males), 1.1 (females)
Fact Sheet for Health Professionals, Riboflavin. National Institute

of Health, Office of Dietary Supplements. https://ods.od.nih.gov/

factsheets/Riboflavin-HealthProfessional/. Updated February 11,
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 9.16 Riboflavin Content of Various Foods”.
Table 9.16 Riboflavin Content of Various Foods
Riboflavin Percent Daily

Food Serving
(mg) Value
Beef liver 3 oz. 2.9 171
1
Breakfast cereals, fortified 1.7 100
serving
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,
½ c. 0.3 18
sliced
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. https://ods.od.nih.gov/
factsheets/Riboflavin-HealthProfessional/. Updated February 11,
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.
Figure 9.12 Conversion of Tryptophan to Niacin

Image by
Allison
Calabrese /
CC BY 4.0
Figure 9.13 Niacin Deficiency, Pellagra

Image by
Herbert L.
Fred, MD,
Hendrik A.
van Dijk /
CC BY-SA
3.0
The RDAs and ULs for different age groups for Niacin are listed in
Table 9.17 “Dietary Reference Intakes for Niacin “. 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 9.17 Dietary Reference Intakes for Niacin

RDA Males and Females mg
Age Group UL
NE/day)
Infants (0–6 Not possible to
2*
months) establish
4*
months) establish
Children (9–13
12 20
years)
16 (males), 14 (females) 30
years)
*denotes Adequate
Intake
Micronutrient Information Center: Niacin. Oregon State University,

Linus Pauling Institute. http://lpi.oregonstate.edu/mic/vitamins/
niacin. 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 9.18 “Niacin Content of Various
Foods”.
Table 9.18 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. http://lpi.oregonstate.edu/mic/vitamins/
niacin. Updated in July 2013. Accessed October 22, 2017.
Pantothenic Acid (B5)
Figure 9.14 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.
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 9.19 “Dietary Reference
Intakes for Pantothenic Acid “.
Table 9.19 Dietary Reference Intakes for Pantothenic Acid
Age Group AI Males and Females mg/day)


Adults (> 19 years) 5
Micronutrient Information Center: Pantothenic Acid. Oregon State

University, Linus Pauling Institute. http://lpi.oregonstate.edu/mic/
vitamins/patothenic-acid . 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 9.20 Pantothenic Acid Content of Various Foods

Pantothenic Acid Percent Daily
Food Serving
(mg) Value
Sunflower seeds 1 oz. 2 20
Fish, trout 3 oz. 1.9 19
Yogurt, plain
8 oz. 1.6 16
nonfat
Lobster 3 oz. 1.4 14
Avocado ½ fruit 1 10
1
Sweet potato 1 10
medium
Milk 8 fl oz. 0.87 8.7
Egg 1 large 0.7 7
Orange 1 whole 0.3 3
Whole wheat
1 slice 0. 21 2.1
bread
Micronutrient Information Center: Pantothenic Acid. Oregon State

vitamins/patothenic-acid . 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.
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 9.21 “Dietary Reference Intakes
for Biotin”.
Table 9.21 Dietary Reference Intakes for Biotin
Age Group AI Males and Females mcg/day)


Adults (> 19 years) 30
Fact Sheet for Health Professionals: Biotin. National Institute of

Health, Office of Dietary Supplements. https://ods.od.nih.gov/
factsheets/Biotin-HealthProfessional/. 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 9.22 Biotin Content of Various Foods”.
Table 9.22 Biotin Content of Various Foods
Biotin Percent Daily

Food Serving
(mcg) 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

factsheets/Biotin-HealthProfessional/. Updated October 3, 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
9.15 “The Function of Vitamin B6 in Amino Acid Metabolism”).
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 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 9.15 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 9.16 Vitamin B6 Functional Coenzyme Role

Image by
Allison
Calabrese /
CC BY 4.0
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.
The RDAs and ULs for different age groups for vitamin B6 are listed
in Table 9.23 “Dietary Reference Intakes for Vitamin B6“.

Table 9.23 Dietary Reference Intakes for Vitamin B6
RDA Males and Females

Age Group UL
mg/day
Not possible to
determine
Not possible to
determine
Children (1–3 years) 0.5 30
Children (4–8 years) 0.6 40
1.3 (males), 1.2 (females) 80
years)
Adults (> 19 years) 1.3 100
*denotes Adequate
Intake
Dietary Supplement Fact Sheet: Vitamin B6. National Institute of

factsheets/VitaminB6-HealthProfessional/. Updates February 11,
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 9.24 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

factsheets/VitaminB6-HealthProfessional/. Updates February 11,
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 9.17 “Folate and the Formation of Macrocytic Anemia”)
Figure 9.17 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 “Spina Bifida in
Infants” ). 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.
Figure 9.18 Spina Bifida in Infants
Spina bifida
is a
neural-tube
defect that
can have
severe health
consequence
s.
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
1mcg 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 9.25 Dietary Reference Intakes for Folate

RDA Males and Females mcg
Age Group UL
DFE/day
65*
months) determine
80*
months) determine
Children (4–8
200 400
years)
Children (9–13
300 600
years)
400 800
years)
Adults (> 19 years) 400 1000
*denotes Adequate
Intake
Dietary Supplement Fact Sheet: Folate. National Institute of Health,

Office of Dietary Supplements. https://ods.od.nih.gov/factsheets/
Folate-HealthProfessional/. 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 “Folate Content of Various
Foods”.
Table 9.26 Folate Content of Various Foods

Folate (mcg Percent Daily
Food Serving
DFE) Value
Beef Liver 3 oz. 215 54
Fortified breakfast
¾ c. 400 100
cereals
Spinach ½ c. 131 33
White rice, enriched ½ c. 90 23
4
Asparagus 85 20
spears
White bread, enriched 1 slice 43 11
2
Broccoli 45 10
spears
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,

Folate-HealthProfessional/. 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 H.pylori
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.
Vitamin B12 Relationship with Folate and

Vitamin B6
Figure 9.19 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 “ Vitamin
B6 Functional Coenzyme Role”, 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 9.20 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.

The RDAs and ULs for different age groups for Vitamin B12 are listed
in Table 9.27 “Dietary Reference Intakes for Vitamin B12“.
Table 9.27 Dietary Reference Intakes for Vitamin B12
Age Group RDA Males and Females mcg/day

Adolescents (14–18 years) 2.4

Adults (> 19 years) 2.4
Dietary Fact Sheet: Vitamin B12. National Institute of Health, Office

of Dietary Supplements. https://ods.od.nih.gov/factsheets/
VitaminB12-HealthProfessional/. Updated February 11, 2016.
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 9.28 “Vitamin B12 Content of Various Foods”.
Table 9.28 Vitamin B12 Content of Various Foods

Vitamin B12 Percent Daily
Food Serving
(mcg) Value
Clams 3 oz. 84.1 1,402
Salmon 3 oz. 4.8 80
Tuna, canned 3 oz. 2.5 42
Breakfast cereals, 1
1.5 25
fortified serving
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. https://ods.od.nih.gov/factsheets/
VitaminB12-HealthProfessional/. Updated February 11, 2016.
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
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.

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 9.29 “Dietary
Reference Intakes for Choline”.
Table 9.29 Dietary Reference Intakes for Choline
Age Group AI Males and Females mg/day) UL
Infants (0–6 months) 125 –

Infants (7–12 months) 150 –
Adolescents (14–18 years) 550 (males), 400 (females) 3000

Fact Sheet for Health Professionals: Choline. National Institute of

factsheets/Choline-HealthProfessional/. Updated January 25, 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 9.30 “Choline Content of Various Foods”.
Table 9.30 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

factsheets/Choline-HealthProfessional/. Updated January 25, 2017.
Summary of Water-Soluble Vitamins
Table 9.31 Water-Soluble vitamins

Recommended Deficiency Gro
Vitamin Sources Intake for Major Functions diseases and risk
adults symptoms def
Orange
juice, Antioxidant,
grapefruit collagen Scurvy,
Sm
Vitamin C juice, synthesis, bleeding gums,
75-90 mg/day alco
(ascorbic acid) strawberries, hormone and joint pain, poor
eld
tomato, neurotransmitter wound healing,
sweet red synthesis
pepper
Beriberi:
Pork, Coenzyme: assists fatigue, Alc
enriched in glucose confusion, old
Thiamin (B1) and whole 1.1-1.2 mg/day metabolism, RNA, movement adu
grains, fish, DNA, and ATP impairment, eat
legumes synthesis swelling, heart diso
failure
Beef liver,
Ariboflavinosis:
enriched Coenzyme: assists
dry scaly skin,
breakfast in glucose, fat and
mouth
cereals, carbohydrate
inflammation
Riboflavin (B2) yogurt, 1.1-1.3 mg/day metabolism, Non
and sores, sore
steak, electron carrier,
throat, itchy
mushrooms, other B vitamins
eyes, light
almonds, are dependent on
sensitivity
eggs
Meat, Coenzyme: assists Pellagra:

poultry, fish, in glucose, fat, diarrhea,
Niacin (B3) peanuts, 14-16 NE/day and protein dermatitis, Alc
enriched metabolism, dementia,
grains electron carrier death
Coenzyme: assists
Sunflower
in glucose, fat,
seeds, fish, Muscle
and protein
Pantothenic dairy numbness and
5 mg/day metabolism, Alc
Acid (B5) products, pain, fatigue,
cholesterol and
widespread irritability
neurotransmitter
in foods
synthesis
Coenzyme; assists
Muscle
in amino-acid
Meat, weakness,
synthesis,
poultry, fish, dermatitis,
B6(Pyridoxine) 1.3-1.7 mg/day glycogneolysis, Alc
legumes, mouth sores,
neurotransmitter
nuts fatigue,
and hemoglobin
confusion
synthesis

Coenzyme; assists
Muscle
Egg yolks, in glucose, fat, Tho
weakness,
fish, pork, and protein con
Biotin 30 mcg/day dermatitis,
nuts and metabolism, raw
fatigue, hair
seeds amino-acid wh
loss
synthesis
Diarrhea,
Leafy green Coenzyme; amino
mouth sores,
vegetables, acid synthesis, Pre
confusion,
Folate enriched 400 mcg/day RNA, DNA, and wom
anemia,
grains, red blood cell alco
neural-tube
orange juice synthesis
defects
Muscle
Coenzyme; fat
weakness, sore
and protein
tongue,
Meats, catabolism, folate Veg
B12(cobalamin) 2.4 mcg/day anemia, nerve
poultry, fish function, eld
damage,
red-blood-cell
neural-tube
synthesis
defects
Non-alcoholic
fatty liver
Egg yolk, Synthesis of disease,
wheat, meat, neurotransmitters muscle
425-550 mg/
Choline fish, and cell damage, Non
day
synthesis in membranes, lipid interfered
the body 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.
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.
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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 9.21 Antioxidants’ Role
Antioxidants | 593
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 9.32 Some Antioxidants Obtained from Diet and Their
Related Functions
594 | Antioxidants
Antioxidant
Antioxidant Antioxidant Function
Source
Protects cellular membranes, prevents
Karat banana,
glutathione depletion, maintains free
Vitamin A beef liver,
radical detoxifying enzyme systems,
chicken liver
reduces inflammation
Sunflower
Protects cellular membranes, prevents
Vitamin E seeds, almonds,
glutathione depletion
sunflower oil
Oranges, Protects DNA, RNA, proteins, and lipids,
Vitamin C
grapefruit aids in regenerating vitamin E
Swordfish,
salmon, tuna
Regulates blood calcium levels in
Vitamin D fish canned in
concert with parathyroid hormone
water and
drained
Pumpkin,
Carotenoids Free radical scavenger
carrots
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Antioxidants | 595


596 | Antioxidants
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
The Body’s Offense | 597

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.
598 | The Body’s Offense

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The Body’s Offense | 599

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 9.33 Some Phytochemical’s Obtained from Diet and Their

Related Functions
600 | Phytochemicals
Phytochemical
Phytochemical Phytochemical Function:
Source
Yellow-orange
May possess strong
Carotenoid fruits, dark green
cancer-fighting properties
leafy vegetables
Cruciferous
May inhibit the development of
vegetables (i.e. bok
Indoles cancer-causing hormones and
choy, broccoli, choy
prevent tumor growth
sum)
May lower the risk for
Grapes, berries,
osteoporosis, heart disease,
Phytoestrogen plums, soybeans,
breast cancer, and menopausal
tofu, garlic
symptoms
May lower blood cholesterol
Grains, nuts,
Stanols levels and reduce the risk of
legumes
heart disease and stroke
May decrease blood lipids, lower
Broad beans, kidney
Saponins cancer risks, and lower blood
beans, lentils
glucose response
May slow cancer cell growth, aid
Terpenes Citrus fruits in immune system support, and
prevent virus related illness
Fruits, vegetables,
May benefit the immune system
Flavonoids chocolates, wines,
and prevent cancer cell growth.
teas, nuts, seeds
Fruits and May prevent cardiovascular
vegetables with disease, reduce cancer cell
Anthocyanidins vibrant colors of proliferation (growth/
orange, red, purple, multiplication) and inhibit tumor
and blue formation.
Coffee, fruits, May prevent cellular damage due
vegetables, nuts, to free-radical oxidation
Phenolic acids cereals, legumes, reaction and promote
oilseeds, beverages anti-inflammatory conditions in
and herbs the body.
Sources:
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.
Bagchi, D., Sen, C. K., Bagchi, M., & Atalay, M. (2004). Anti-
Phytochemicals | 601
angiogenic, antioxidant, and anti-carcinogenic properties of a novel
anthocyanin-rich berry extract formula. Biochemistry. Biokhimiia,
69(1), 75–80, 1 p preceding 75. https://doi.org/10.1023/
b:biry.0000016355.19999.93
Flavonoids. (2014, April 28). Linus Pauling Institute.

https://lpi.oregonstate.edu/mic/dietary-factors/
phytochemicals/flavonoids
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. https://doi.org/10.1155/2010/483958
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.
https://doi.org/10.1016/j.phrs.2007.01.009
Kozłowska, A., & Szostak-Wegierek, D. (2014). Flavonoids—Food

sources and health benefits. Roczniki Panstwowego Zakladu Higieny,
65(2), 79–85.
Patisaul, H. B., & Jefferson, W. (2010). The pros and cons of

phytoestrogens. Frontiers in Neuroendocrinology, 31(4), 400–419.
https://doi.org/10.1016/j.yfrne.2010.03.003
Phenolic Acids—An overview | ScienceDirect Topics. (n.d.). Retrieved

June 29, 2020, from https://www-sciencedirect-
com.eres.library.manoa.hawaii.edu/topics/food-science/
phenolic-acids
Phytochemicals—Final.pdf. (n.d.). Retrieved June 9, 2020, from

https://www1.villanova.edu/content/dam/villanova/studentlife/
documents/healthpromotion/Phytochemicals%20-%20Final.pdf
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.
https://doi.org/10.1089/109662004322984734
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. https://doi.org/10.1016/j.amjcard.2005.03.013
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). https://doi.org/10.3390/ijms18010096
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. https://doi.org/10.1080/10408398.2013.805316
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.,
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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. https://doi.org/10.1017/S0007114513000688
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PART X
CHAPTER 10. MAJOR
MINERALS
Chapter 10. Major Minerals | 607

Introduction
He pūko`a kani `āina
A coral reef strengthens into land.
Choy Sum by
pxhere.com
/ CCO
Learning Objectives
Introduction | 609
• Describe the functional role, intake
recommendations and sources of major minerals
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
1
individual’s ability to meet their nutrient needs.
Figure 10.1 The Major Minerals
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. http://apjcn.nhri.org.tw/server/
APJCN/17/1/94.pdf. Accessed February 16, 2018.
610 | Introduction
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
Introduction | 611
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.
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612 | Introduction
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
Calcium | 613
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.
Figure 10.2 Maintaining Blood Calcium Levels
614 | Calcium
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
Calcium | 615
100 milligrams of calcium consumed daily, systolic blood
pressure is reduced 0.34 millimeters of mercury (mmHg) and
1
diastolic blood pressure is decreased by 0.15 mmHg.
• 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.
Figure 10. 3 Calcium’s Effect on Aging
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. http://aje.oxfordjournals.org/content/148/3/
223.long. Accessed October 10, 2017.
616 | Calcium
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 | 617
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
23
decrease bone mass. 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
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. http://www.ncbi.nlm.nih.gov/
pubmed/2294327?dopt=Abstract. . Accessed November
22, 2017.
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. http://www.ncbi.nlm.nih.gov/
pubmed/3966752?dopt=Abstract. Accessed November
22, 2017.
618 | Calcium
stress issues are related to an increased susceptibility to future
45
stress fractures.
• 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
6
inadequacy is great.
• 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
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.
11101266?dopt=Abstract.,.Accessed November 22, 2017.
5. Johnson AO, et al. (1993). Correlation of Lactose
Maldigestion, Lactose Intolerance, and Milk Intolerance.
8438774?dopt=Abstract. Accessed November 22, 2017.
6. Calcium and Vitamin D in the Elderly. International
Osteoporosis Foundation.
http://www.iof bonehealth.org/patients-public/about-
osteoporosis/prevention /nutrition/calcium-and-
vitamin-d-in-the-elderly.html. Published 2012. Accessed
November 22, 2017.
Calcium | 619
in calcium absorption. During the first years of menopause,
annual decreases in bone mass range from 3–5 percent. After
7
age sixty-five, decreases are typically less than 1 percent.
• 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.
• Vegans. Vegans typically absorb reduced amounts of calcium
because their diets favor plant-based foods that contain
8
oxalates and phytates.
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
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
D.Food and Nutrition Board, Institute of Medicine.
Washington, DC: National Academy Press. 2010.
620 | Calcium
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
9
of the stated calcium content.
9. Ross EA, Szabo NJ, Tebbett IR. (2000). Lead Content of
Calcium | 621
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
Calcium Supplements. The Journal of the American

Medical Association, 284, 1425–33.
622 | Calcium
greater than 500 milligrams per day in the absence of a vitamin
D supplement had a 30 percent greater risk for having a heart
10
attack.
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.
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
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).
Calcium | 623
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 “Dietary Reference Intakes for Calcium”. 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 10.1 Dietary Reference Intakes for Calcium
624 | Calcium
Age Group RDA (mg/day) UL (mg/day)

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

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. http://www.ncbi.nlm.nih.gov/pubmed/21118827.
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.
Calcium | 625
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 (http://www.nal.usda.gov/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.
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
626 | Calcium
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 10.2 Calcium Content and Bioavailability of Various Foods
Calcium | 627
Estimated
% %
Calcium Absorption Calcium
Food Serving Daily Daily
(mg) (%) Absorbed
Value1 Value2
(mg)
Yogurt, low
8.5 oz. 300 32 96 7.4 9.6
fat
Mozzarella,
1.5 oz. 333 32 107 8.2 10.7
part skim
Sardines,
canned 3 oz. 325 27 88 6.8 8.8
with bones
Cheddar
1.5 oz. 303 32 97 7.5 9.7
Cheese
Milk, nonfat 8.5 oz. 300 32 96 7.4 9.6

Soymilk,
calcium 8.5 oz. 300 24 72 5.5 7.2
fortified
Orange
juice,
8.5 oz. 300 36 109 8.4 10.9
calcium
fortified
Tofu, firm,
made with
½ c. 258 31 80 6.2 8.0
calcium
sulfate
Salmon,
canned 3 oz. 181 27 49 3.8 4.9
with bones
Turnip
½ c. 99 52 51 4.0 5.1
Greens
Kale,
1 c. 94 49 30 2.3 3.0
cooked
Vanilla Ice
Cream, ½ c. 84 32 27 2.1 2.7
light
Broccoli,
1 c. 35 61 19 1.5 1.9
cooked
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
628 | Calcium
1
Based on DV = 1000 mg
2
Based on DV = 1300 mg
Source:
Office of Dietary Supplements. (2020, March 26). Calcium.
https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/
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/j.jfca.2006.04.013
Learning Activities

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Calcium | 629
630 | Calcium
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 10.3 Dietary Reference Intakes for Phosphorus
Phosphorus | 631
Age Group RDA (mg/day) UL (mg/day)


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
Micronutrient Information Center: Phosphorus. Oregon State

minerals/phosphorus. Updated in July 2013. Accessed October 22,
2017.
Dietary Sources of Phosphorus
Table 10.4 Phosphorus Content of Various Foods
632 | Phosphorus
Phosphorus Percent Daily Value
Foods Serving
(mg) 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
12 oz. 41 4
drink
Bread, enriched 1 slice 25 3
Micronutrient Information Center: Phosphorus. Oregon State

minerals/phosphorus. Updated in July 2013. Accessed October 22,
2017.
Learning Activities

Phosphorus | 633
Open Document).


634 | Phosphorus
Sulfur
Sulfur is incorporated into protein structures in the body. Amino

acids, methionine and cysteine contain sulfur which are essential
for the antioxidant enzyme glutathione peroxidase. Some vitamins
like thiamin and biotin also contain sulfur which are important in
regulating acidity in the body. Sulfur is a major mineral with no
recommended intake or deficiencies when protein needs are met.
Sulfur is mostly consumed as a part of dietary proteins and sulfur
containing vitamins.
Sulfur’s Functional Role
Sulfur is the third most abundant mineral in our body after calcium
1
and phosphorus. Sulfur is incorporated into protein structures in
the body such as keratin in hair and provides stabilization to these
protein structures. One of it’s key roles is the synthesis of 3’-
2
phosphoadenosine-5’phosphosulfate (PAPS) which is used in the
1. Nimni, M. E., Han, B., & Cordoba, F. (2007). Are we

getting enough sulfur in our diet?. Nutrition &
Metabolism, 4,24. https://doi.org/10.1186/
1743-7075-4-24.
2. Weiss, M., Steiner, D. F., & Philipson, L. H. (2000). Insulin
biosynthesis, secretion, structure, and structure-activity
Sulfur | 635
biosynthesis of compounds essential in chondroitin in bones and
3
cartilage, heparin and insulin. Additionally, sulfur is an important
component of the antioxidant enzyme glutathione peroxidase.
Excess cysteine and methionine are oxidized to sulfate and excreted
4
in the urine or stored as glutathione.
Dietary Reference Intakes for Sulfur
Sulfur is a major mineral with no recommended intake. Deficiencies

are not found in those that meet protein requirements or in those
with adequate consumption of sulfur-containing amino acids.
Adverse effects were reported in individuals that ingest water
sources with high levels of inorganic sulfur. Osmotic diarrhea may
result and is of particular concern in infants. Animal studies showed
that growth is stunted with inadequate sulfur intake from foods
and beverages. Current data is insufficient to establish a Tolerable
5
Upper Intake Level (UL).
relationships. In K. R. Feingold (Eds.) et. al., Endotext.

MDText.com, Inc.
3. Weiss, M., Steiner, D. F., & Philipson, L. H. (2000). Insulin
biosynthesis, secretion, structure, and structure-activity
relationships. In K. R. Feingold (Eds.) et. al., Endotext.
MDText.com, Inc.
1743-7075-4-24.
5. Institute of Medicine. (2006). Dietary Reference Intakes:
636 | Sulfur
Dietary Sources of Sulfur
Dietary sources mainly come from sulfur-containing amino acids

methionine and cysteine. Some vitamins like thiamin and biotin
contain sulfur which are important in regulating acidity in the body.
Sulfur can also be obtained from sulfur-containing foods such as
6
garlic, onion and cruciferous vegetables. Tap water also supplies
7
sulfur but its concentration varies depending on location. Dietary
supplements such as chondroitin sulfate or glucosamine sulfate
8
commonly used to aid bone and joint health also contain sulfur.
Table 10.5 Sulfur Content in Various Foods
The Essential Guide to Nutrient Requirements.

Washington, DC: The National Academies Press.
https://doi.org/10.17226/11537.
6. Institute of Medicine. (2006). Dietary Reference Intakes:
The Essential Guide to Nutrient Requirements.
https://doi.org/10.17226/11537.
7. Doleman, J. F., Grisar, K., Van Liedekerke, L., Saha, S.,
Roe, M., Tapp, H. S., & Mithen, R. F. (2017). The
contribution of alliaceous and cruciferous vegetables to
dietary sulphur intake. Food Chemistry, 234, 38–45.
https://doi.org/10.1016/j.foodchem.2017.04.098.
1743-7075-4-24.
Sulfur | 637
Methionine Cystine
Food Serving
(mg) (mg)
Turkey breast 1 breast 7102 2442
Brazil nuts 1 cup 1495 407
Canned tuna 1 cup 1259 456
Swiss Cheese,
1 cup 1035 383
diced
Canned green
1 can 257 0.172
peas
Egg, whole 1 large 189 136
Dried peaches 1 cup 139 46
Sweet potatoes 1 cup 134 43
Russet potatoes, 1 large potato (3” to 4-¼”
123 93
baked diameter)
Whole-grain
1 slice 36 46
bread
Broccoli ½ cup 34 24
Cauliflower ½ cup 16 13
Source: USDA Standard Reference Legacy Nutrient Search
Learning Activities

Open Document).

638 | Sulfur

Sulfur | 639
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
1
correlated to an increased BMD in the hip. 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
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. http://www.ajcn.org/cgi/
October 6, 2017.
640 | Magnesium
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 10.6 Dietary Reference Intakes for Magnesium
Magnesium | 641
RDA (mg/ UL from non-food sources (mg/
Age Group
day) day)
410 350
years)
Adults (19–30 years) 400 350
* denotes Adequate
Intake
Source: Dietary Supplement Fact Sheet: Magnesium. National

http://ods.od.nih.gov/factsheets/Magnesium-
HealthProfessional/. 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.
Table 10.7 Magnesium Content of Various Foods
642 | Magnesium
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

http://ods.od.nih.gov/factsheets/Magnesium-
HealthProfessional/. Updated July 13, 2009. Accessed November 12,
2017.
Learning Activities

Magnesium | 643
Open Document).


644 | Magnesium
Summary of Major Minerals
Table 10.8 A Summary of the Major Minerals
Summary of Major Minerals | 645

Recommended Deficiency
Groups a
Micronutrient Sources Intakes for Major functions diseases and
for defic
adults symptoms
Yogurt,
cheese, Component of Postmen
sardines, mineralized bone, Increased women,
Calcium milk, 1,000 mg/day provides risk of who are
orange structure and osteoporosis actosein
juice, microarchitecture or vegan
turnip
Salmon,
Structural
yogurt,
component of
turkey, Bone loss, Older ad
Phosphorus 700 mg/day bones, cell
chicken, weak bones alcoholic
membrane, DNA
beef,
and RNA, and ATP
lentils
Whole
Component of
grains and
mineralized bone,
legumes, Tremor, Alcoholic
ATP synthesis and
almonds, muscle individua
utilization,
Magnesium cashews, 420 mg/day spasms, loss kidney a
carbohydrate,
hazelnuts, of appetite, gastroint
lipid,protein,
beets, nausea disease
RNA, and DNA
collards,
synthesis
and kelp
Structure of some None when
Protein None vitamins and protein
Sulfur None
foods specified amino acids, needs are
acid-base balance met
Major positive People
Processed extracellular ion, consumi
foods, < 2,300 mg/ nerve much wa
Muscle
Sodium table salt, day; ideally transmission, excessive
cramps
pork, 1,500 mg/day muscle sweating
chicken contraction, fluid with vom
balance diarrhea
Major positive People
Fruits,
intracellular ion, consumi
vegetables, Irregular
nerve high in
legumes, heartbeat,
Potassium 4700 mg/day transmission, processe
whole muscle
muscle meats, th
grains, cramps
contraction, fluid with vom
milk
balance diarrhea
Table salt, <3600 mg/ Major negative
Chloride processed day; ideally extracellular ion, Unlikely none
foods 2300 mg/day fluid balance
646 | Summary of Major Minerals

Learning Activities

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Summary of Major Minerals | 647


648 | Summary of Major Minerals

PART XI
CHAPTER 11. TRACE
MINERALS
Chapter 11. Trace Minerals | 649

Introduction
Li‘ili‘i ka ‘ōhiki, loloa ka lua
Small is the crab, large is the hole
Wakame
Salad
Seaweed
Food
Cooking by
maxpixel.co
m / CCO
Learning Objectives
• Describe the functional role, intake
Introduction | 651
recommendations and sources of trace minerals
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
1
made in decreasing the prevalence of iodine deficiency in Fiji.
Figure 11.1 The Trace Minerals
1. Micronutrient Deficiencies. (2015). Ministry of Health

and Medical Services, Shaping Fiji’s Health.
http://www.health.gov.fj/?page_id=1406. Accessed
November 12, 2017.
652 | Introduction
Image by
Allison
Calabrese /
CC BY 4.0
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Introduction | 653

654 | Introduction
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 11.2 The Structure of Hemoglobin
Image by
Allison
Calabrese /
CC BY 4.0
Iron | 655
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,
1
and that from vegetarian diets ranges between 5 and 12 percent.
1. Centers for Disease Control and Prevention. “Iron and

Iron Deficiency.” Accessed October 2, 2011.
656 | Iron
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 11.1 Enhancers and Inhibitors of Iron Absorption
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 11.3 Iron Absorption, Functions, and Loss
http://www.cdc.gov/nutrition/everyone/basics/
vitamins/iron.html.
Iron | 657
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
11.2 “Dietary Reference Intakes for Iron”). 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 similar to those of iron overload
658 | Iron
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 11.2 Dietary Reference Intakes for Iron
UL(mg/
Age Group RDA(mg/day)
day)
Infant (0–6 months) 0.27* 40

11 (males), 15
(females)
8 (males), 18
Adults (19–50 years) 45
(females)
Dietary Sources of Iron
Table 11.3 Iron Content of Various Foods
Iron | 659
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
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
• Dizziness
• Swollen, sore tongue
660 | Iron
• 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 “Enhancers and Inhibitors of Iron
Absorption” 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
2
worldwide. The WHO estimates that 80 percent of people are iron
2. Iron and Iron Deficiency. Centers for Disease Control

and Prevention. http://www.cdc.gov/nutrition/
Iron | 661
deficient and 30 percent of the world population has iron-
3
deficiency anemia. 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
everyone/basics/vitamins/iron.html.Accessed October
2, 2011.
3. Anemia. The World Bank. http://web.worldbank.org/
WBSITE/EXTERNAL/TOPICS/
EXTHEALTHNUTRITIONANDPOPULATION/
EXTPHAAG/
0,,contentMDK:20588506~menuPK:1314803~pagePK:642
29817~piPK:64229743 ~theSitePK:672263,00.html.
662 | Iron
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
Iron | 663
occur in Africa and Southeast Asia. The World Bank states five key
4
interventions to combat anemia:
• 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.
• 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.
Learning Activities
4. Anemia. The World Bank. http://web.worldbank.org/

WBSITE/EXTERNAL/TOPICS/
EXTHEALTHNUTRITIONANDPOPULATION/
EXTPHAAG/
0,,contentMDK:20588506~menuPK:1314803~pagePK:642
29817~piPK:64229743
~theSitePK:672263,00.html. Accessed October 2, 2011.
664 | Iron
Open Document).


Iron | 665
Copper
Copper, like iron, assists in electron transfer in the electron-

transport chain. It is also an enzyme cofactor essential for iron
absorption and transport. The other important function of copper
is as an antioxidant. It is naturally present in several foods and
1
is generally accessible as a dietary supplement. A typical adult
2
body has a total copper content of 50-120 mg. The body maintains
copper level balance through absorption from the intestine and the
3
release of copper by the liver into bile. Current studies indicate
that copper deficiency may be more frequent than what was
previously discovered, while copper toxicity is rare due to
4
conventional diets. Symptoms of mild to moderate copper
1. Collins JF. Copper. In: Ross AC, Caballero B, Cousins RJ,

Tucker KL, Ziegler TR, eds. Modern Nutrition in Health
and Disease. 11th ed. Baltimore, MD: Lippincott Williams
& Wilkins; 2014:206-16.
2. Prohaska JR. Copper. In: Erdman JW, Macdonald IA,
Zeisel SH, eds. Present Knowledge in Nutrition. 10th ed.
Washington, DC: Wiley-Blackwell; 2012:540-53.
3. Institute of Medicine, Food and Nutrition Board. Dietary
Reference Intakes for Vitamin A, Vitamin K, Arsenic,
Boron, Chromium, Copper, Iodine, Iron, Manganese,
Molybdenum, Nickel, Silicon, Vanadium, and Zinc.
Washington, DC: National Academies Press; 2001.
4. de Romaña, D. L., Olivares, M., Uauy, R., & Araya, M.
666 | Copper
deficiency are uncommon. More severe copper deficiency can
cause anemia from the lack of iron mobilization in the body for
red blood cell synthesis. Other signs and symptoms include growth
retardation in children and neurological problems because copper
is a cofactor for an enzyme that synthesizes myelin, which
surrounds many nerves.
Dietary Reference Intakes for Copper
Table 1: Dietary Reference Intakes for Copper
(2011). Risks and benefits of copper in light of new

insights of copper homeostasis. Journal of Trace
Elements in Medicine and Biology: Organ of the Society
for Minerals and Trace Elements (GMS), 25(1), 3–13.
https://doi.org/10.1016/j.jtemb.2010.11.004
Copper | 667
DRI values (μg/day)
Life stage group RDA
Infants (0-12 months) –
Children (1-3 years) 340
Adolescents (14-18 years) 890
Adults (>18 years) 900
1
Not Determinable
Source:
The National Academies Press (2006). Dietary Reference Intakes:
The Essential Guide to Nutrient Requirements. The National
Academies of Sciences Engineering Medicine.
Dietary Sources of Copper
Copper is distributed in many foods and is abundant in organ meats,

seafoods, nuts, and seeds. Wheat bran cereals, whole grains and
cocoa products are also good sources of copper. The absorption
of copper from foods may be reduced by excess intakes of zinc
and the amino acid histidine in addition to high intakes of iron and
fructose. Copper is also available as part of other ingredients in a
multimineral supplement or by itself in a copper only supplement.
668 | Copper
Dietary supplements containing copper typically range from a few
5
micrograms to 15 mg.
Learning Activities

Open Document).

5. Institute of Medicine (US) Panel on Micronutrients.

(2001). Dietary reference intakes for vitamin A, vitamin K,
arsenic, boron, chromium, copper, iodine, iron,
manganese, molybdenum, nickel, silicon, vanadium, and
zinc. Washington (DC): National Academies Press (US); 7,
Copper.
Copper | 669
670 | Copper
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
1
diet.
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.
1. Prasad, Ananda. (2003). Zinc deficiency. British Medical

Journal, 326(7386), 409–410. doi: 10.1136/
bmj.326.7386.409. Accessed October 2, 2011.
PMC1125304/?tool=pmcentrez.
Zinc | 671
Dietary Reference Intakes for Zinc
Table 11.4 Dietary Reference Intakes for Zinc
UL(mg/
Age Group RDA(mg/day)
day)
Infant (0–6 months) 2* 4
Infants (6–12 months) 3 5

11 (males), 9
(females)
11 (males), 8
Adults (19 + years) 40
(females)
Fact Sheet for Health Professionals: Zinc. National Institute of

factsheets/Zinc-HealthProfessional/. Updated February 11, 2016.
Dietary Sources of Zinc
Table 11.5 Zinc Content of Various Foods
672 | Zinc
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
Fact Sheet for Health Professionals: Zinc. National Institute of

factsheets/Zinc-HealthProfessional/. Updated February 11, 2016.
Learning Activities

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Zinc | 673

674 | Zinc
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
Selenium | 675
1
differences among different studies. 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 11.4 Selenium’s Role in Detoxifying Free Radicals
1. Dennert G, Zwahlen M, et al. (2011). Selenium for

Preventing Cancer. Cochrane Database of Systematic
Reviews,5. http://www.ncbi.nlm.nih.gov/pubmed/
21563143. Accessed November 22, 2017.
676 | Selenium
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 11.6 “Dietary Reference Intakes for Selenium”.
Table 11.6 Dietary Reference Intakes for Selenium
Selenium | 677
Age Group RDA Males and Females mcg/day UL


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 11.7 Selenium Contents of Various Foods
678 | Selenium
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

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
Source: US Department of Agriculture, Agricultural Research

Service. 2010. USDA National Nutrient Database for Standard
Reference, Release 23. http://www.ars.usda.gov/ba/bhnrc/ndl.
Learning Activities

Selenium | 679
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680 | Selenium
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. 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
1
number-one cause of preventable brain damage worldwide.
Figure 11.5 Deaths Due to Iodine Deficiency Worldwide in 2012
1. World Health Organization. “Iodine Status Worldwide.”

Accessed October 2, 2011. http://whqlibdoc.who.int/
publications/2004/9241592001.pdf.
Iodine | 681
Image by
Chris55 / CC
BY 4.0
Figure 11.6 Iodine Deficiency: Goiter

A large
goiter by Dr.
J.S.Bhandari,
India / CC
BY-SA 3.0
Dietary Reference Intakes for Iodine
Table 11.8 Dietary Reference Intakes for Iodine
682 | Iodine
Age Group RDA Males and Females mcg/day UL
Infants (0–6 months) 110*

Infants (7–12 months) 130*

Adults (> 19 years) 150 1,100
Health Professional Fact Sheet: Iodine. National Institute of Health,

Iodine-HealthProfessional/. 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 11.9 Iodine Content of Various Foods
Iodine | 683
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,

Iodine-HealthProfessional/. Updated June 24, 2011. Accessed
November 10, 2017.
Learning Activities

Open Document).

684 | Iodine

Iodine | 685
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
1
high in chromium include the liver, spleen, and bone.
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.
1. Gropper, S. A. S., Smith, J. L., & Carr, T. P. (2018).

Advanced nutrition and human metabolism. Boston, MA:
Cengage Learning.
686 | Chromium
Table 1: Dietary Reference Intakes for Chromium
Age Group AI (μg/day)
Infants (0-6 months) 0.2
Infants (6-12 months) 5.5
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
2
grains. . Accessed December 5, 2019.
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. https://doi.org/10.1007/
bf02784595
Chromium | 687
Learning Activities

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688 | Chromium
Manganese
Manganese is a cofactor for enzymes that are required for

carbohydrate and cholesterol metabolism, bone formation, and the
synthesis of urea. Those who suffer from liver failure are at greater
risk for manganese toxicity because the mineral’s homeostasis is
maintained largely by the liver with excretion of excess manganese
occurring via bile. Manganese deficiency is uncommon. If a
deficiency occurs from elimination from the diet, signs and
symptoms include but are not limited to nausea, vomiting,
dermatitis, decreased growth of hair and nails, and poor bone
1
formation and skeletal defects.
Dietary Reference Intake of Manganese

The recommended intake for manganese is 2.3 mg per day for
adult males and 1.8 mg per day for adult females. The Tolerable
Upper Intake Level for adults is 11 mg/day.

Cengage Learning.
Manganese | 689
Table 1: Dietary Reference Intakes for Manganese
Age group AI (mg/day) UL (mg/day)
Infants (0-6 months) 0.003 –
Infants (6-12 months) 0.6 –
Children (1-3 years) 1.2 2
Adolescents (14-18 years) 2.2 (males), 1.6 (females) 9
Adults (>18 years) 2.3 (males), 1.8 (females) 11

Intakes: The Essential Guide to Nutrient Requirements. The
National Academies of Sciences Engineering Medicine. 350.
Dietary Sources of Manganese:

The best food sources for manganese are whole grains, nuts,
legumes, and green vegetables.
Learning Activities

690 | Manganese
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Manganese | 691
Molybdenum
Molybdenum also acts as a cofactor that is required for the

metabolism of sulfur-containing amino acids, nitrogen-containing
compounds found in DNA and RNA, and various other functions.
Deficiency of molybdenum is not seen in healthy people, however, a
rare metabolic effect called molybdenum cofactor deficiency is the
result of an insufficient amount of molybdoenzymes in the body.
Due to rapid excretion rates in the urine of the mineral,
molybdenum toxicity is low in humans.
Dietary Reference Intakes of Molybdenum:

The recommended intake for molybdenum is 45 mcg per day for
both adult males and females.
Table 1: Dietary Reference Intakes for

Molybdenum
RDA (μg/ UL (μg/

Age group
day) day)
Children (1-3 years) 17 300

Children (4-8 years) 22 600
Children (9-13 years) 34 1,100

Adolescents (14-18 years) 43 1,700
Adults (19-50 years) 45 2,000
Adults (51-70 years) 45 2,000

Adults (>71 years) 45 2,000
692 | Molybdenum
Intakes: The Essential Guide to Nutrient Requirements. The
National Academies of Sciences Engineering Medicine. 356.
Dietary Sources of Molybdenum:
The food sources of molybdenum varies depending on the
content in the soil in the specific region. Legumes, grain products,
and nuts are rich sources of dietary molybdenum. Animal products,
1
fruits, and most vegetables are low in molybdenum.
Learning Activities

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Cengage Learning.
Molybdenum | 693
694 | Molybdenum
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
1
century .
The optimal fluoride concentration in water to prevent tooth
1. 10 Great Public Health Achievements in the 20th

Century. (1999). Centers for Disease Control, Morbidity
and Mortality Weekly Report, 48(12), 241–43.
http://www.cdc.gov/about/history/tengpha.htm.
Fluoride | 695
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 11.7 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.
696 | Fluoride
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 11.10 Dietary Reference Intakes for Fluoride
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
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. .
http://www.iom.edu/Reports/1997/Dietary-Reference-Intakes-
for-Calcium-Phosphorus-Magnesium-Vitamin-D-and-
Fluoride.aspx.
Fluoride | 697
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 11.11 Fluoride Content of Various Foods
Fluoride Percent Daily

Food Serving
(mg) Value*
3.5 fl
Fruit Juice 0.02-2.1 0.7-70
oz.
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. lpi.oregonstate.edu/mic/
minerals/fluoride . Updated in April 29, 2015. Accessed October 22,
2017.
698 | Fluoride
Learning Activities

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Fluoride | 699
Summary of Trace Minerals
Table 11.12 Summary of the Trace Minerals
700 | Summary of Trace Minerals

Recommended Deficiency Gr
Micronutrient Sources Intakes for Major Functions diseases and ris
adults symptoms de
In
Red meat, pr
egg yolks, Assists in energy Anemia: ch
dark leafy production, DNA fatigue, ad
Iron vegetables, 8-18 mg/day synthesis required paleness, w
dried fruit, for red blood cell faster heart pr
iron-fortified function rate w
foods at
ve
Anemia: Th
Nuts, seeds, Assists in energy fatigue, co
Copper whole grains, 900 mcg/day production, iron paleness, ex
seafood metabolism faster heart zi
rate su
Oysters,
Growth
wheat germ,
Assists in energy retardation in
pumpkin
production, protein, children, hair
seeds,
RNA and DNA loss, diarrhea, Ve
Zinc squash,, 8-11 mg/day
synthesis; required skin sores, ol
beans,
for loss of
sesame
hemoglobinsynthesis appetite,
seeds, tahini,
weight loss
beef, lamb
Fatigue,
Po
Meat, muscle pain,
Essential for thyroid w
Selenium seafood, 55 mcg/day weakness,
hormone activity so
eggs, nuts Keshan
se
disease
Goiter,
cretinism,
other signs
and Po
Iodized salt, Making thyroid symptoms w
seaweed, hormone, include so
Iodine 150 mcg/day
dairy metabolism, growth fatigue, io
products and development depression, io
weight gain, no
itchy skin,
low
heart-rate
Assists insulin in
Meats, nuts abnormal
25-35 mcg/ carbohydrate, lipid M
Chromium and whole glucose
day and protein ch
grain metabolism
metabolism
Summary of Trace Minerals | 701

Component of
Fluoridated
mineralized bone,
water, foods Po
provides structure Increased risk
prepared in w
Fluoride 3-4 mg/day and of dental
fluoridated flu
microarchitecture, caries
water, w
stimulates new bone
seafood
growth
Impaired
growth,
Legumes,
Glucose synthesis, skeletal
nuts, leafy 1.8-2.3 mg/
Manganese amino-acid abnormalities, No
green day
catabolism abnormal
vegetables
glucose
metabolism
Milk, grains, Cofactor for a

Molybdenum 45 mcg/day Unknown No
legumes number of enzymes
Learning Activities

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Summary of Trace Minerals | 703


PART XII
CHAPTER 12. NUTRITION
APPLICATIONS
Chapter 12. Nutrition

Applications | 705
Introduction
Pū‘ali kalo i ka we ‘ole
Taro, for lack of water, grows misshapen.
North Shore
Taro by
Richard
Doyle / CC
BY-NC 3.0
Learning Objectives
Introduction | 707
• Describe the purpose and function of nutrition
recommendations
• Describe steps towards building healthy eating
patterns
• Interpret the Nutrition Facts labels found on food
items
• Describe the purpose and use of the MyPlate
Planner, the Secretariat of the Pacific Community
(SPC) Guidelines and the Pacific Food Guide
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 example, many Pacific Islanders have been
unable to maintain their traditional diets for various environmental,
social and demographic reasons. This has resulted in diets high in
a variety of high-calorie, nutrient-poor foods. Frequent inadequate
and/or excessive nutrient intake can lead to many health issues in
a community such as obesity, diabetes, heart disease and cancer.
Therefore, it is important to employ moderation and portion control
by using all of the principles together to afford you lasting health
1
benefits .
1. Pacific Food Summit: Factsheet. (2010). World Health

Organization. http://www.wpro.who.int/mediacentre/
factsheets/fs14042010/en/. Accessed November 28,
2017.
708 | Introduction
Learning Activities

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Introduction | 709
Understanding Dietary
Reference Intakes
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
“Dietary Reference Intakes” (DRI) is an umbrella term for four

reference values:
• Estimated Average Requirements (EAR)

• Recommended Dietary Allowances (RDA)
• Adequate Intakes (AI)
• Tolerable Upper Intake Levels (UL)
The DRIs are not minimum or maximum nutritional requirements

and are not intended to fit everybody. They are to be used as guides
1
only for the majority of the healthy population .
1. Deng S, West BJ, Jensen CJ. (2010). A Quantitative

Comparison of Phytochemical Components in Global
Noni Fruits and Their Commercial Products. Food
710 | Understanding Dietary
Reference Intakes
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.
Chemistry, 122(1), 267–70.

http://www.sciencedirect.com/science/article/pii/
S0308814610001111. Accessed December 4, 2017.
Understanding Dietary Reference Intakes | 711

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, 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
712 | Understanding Dietary Reference Intakes

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 12.1 DRI Graph

Image by
Allison
Calabrese /
CC BY 4.0
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: Dietary Reference Intakes Tables and Application. The
National Academies of Science, Engineering, and Medicine. Health
and Medicine Division. http://nationalacademies.org/HMD/
Activities/Nutrition/SummaryDRIs/DRI-Tables.aspx. Accessed
November 22, 2017.
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 adequate of the
essential nutrients and is associated with a reduced risk of chronic
disease. The ranges listed in Table 12.1 “Acceptable Macronutrient
Distribution Ranges (AMDR) For Various Age Groups” allows
individuals to personalize their diets taking into consideration that
different subgroups in a population often require different
requirements. The DRI committee recommends using the midpoint
2
of the AMDRs as an approach to focus on moderation .
Table 12.1 Acceptable Macronutrient Distribution Ranges (AMDR)
For Various Age Groups
2. Dietary Reference Intakes Tables and Application. The

National Academies of Science, Engineering, and
Medicine. Health and Medicine Division.
http://nationalacademies.org/HMD/Activities/
Nutrition/SummaryDRIs/DRI-Tables.aspx. Accessed
November 22, 2017.

Protein Carbohydrates Fat
Age Group
(%) (%) (%)
Children (1–3) 5–20 45–65 30–40
Children and Adolescents
10–30 45–65 25–35
(4–18)
Adults (>19) 10–35 45–65 20–35
Source: Food and Nutrition Board of the Institute of Medicine.

Dietary Reference Intakes for Energy, Carbohydrate, Fat, Fatty
Acids, Cholesterol, Protein, and Amino Acids.
http://www.nationalacademies.org/hmd/~/media/Files/
Activity%20Files/Nutrition/DRI-Tables/
8_Macronutrient%20Summary.pdf?la=en. Published 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.

Learning Activities

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Discovering Nutrition Facts
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
(NLEA) 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.
In May, 2016 a new Nutrition Facts label for packaged foods,
beverages and dietary supplements was announced. This label
reflects new scientific information and will make it easier for
consumers to make informed food choices. Some of the changes
made to the label include:
• Increased type size for “Calories,” “servings per container,” and

“Serving size.”
• Bolded type for the number of calories and the “Serving size.”
• Actual amounts of vitamin D, calcium, iron, and potassium (in
addition to the Daily Value amounts) are required to be listed.
Vitamins A and C are now voluntary.
• Improved footnote to better explain that the Daily Value is
based on a 2,000 calories a day diet.
718 | Discovering Nutrition Facts

• Changed “Sugars” to “Total Sugars”. Added “Includes” to clarify
that “added sugars” is a subcomponent of “total sugars.”
• “Added sugars” in grams and percent Daily Value are required
to be listed due to scientific data the impact of added sugars
on caloric intake. Added sugars are either added during
processing of foods, or are packaged as such, and include
items such as: syrups, maltose, and invert sugar.
• “Total Fat,” “Saturated Fat,” “Trans Fat,” “Cholesterol,” “Total
Carbohydrates” are still required on the label.
• “Calories from fat” has been removed because the type of fat is
important.
• Updated values for sodium, dietary fiber, and vitamin D (which
are all required on the label) based on newer scientific
research.
• Updated serving sizes that reflect how much consumers are
more likely eating today.
• Some packages with serving sizes between one and two are
required to be labelled as one serving since most consumers
will likely eat it in one sitting
• Dual columns for certain products that are larger than a single
serving but could be consumed in one sitting will indicate “per
serving” and “per package” amounts.
• Percent DV of some nutrients were updated due to newly
available scientific data.
• The compliance date for manufacturers to adopt the new label
was extended to January 1, 2020. Manufacturers with less than
$10 million in annual food sales will have until January 1, 2021.
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
Discovering Nutrition Facts | 719

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 RDA of that nutrient in a
2,000-kilocalorie diet. The DV was updated as part of the new
nutrition facts label announced in May 2016. The updated DV applies
to packaged food, beverages and dietary supplements that contain
ingredients with a DV. 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
older food label in Figure 12.2 “Reading the Older Nutrition Label,”
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 1,300 milligrams, the food producer
determined the percent DV for calcium by taking the calcium
content in milligrams in each serving, and dividing it by 1,300
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.
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
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 12.2 Updated DVs Based on a Caloric Intake of 2,000
Calories (For Adults and Children Four or More Years of Age)

Nutrient Original DV
Total Fat 65 g
Saturated Fat 20 g
Cholesterol 300 mg
Sodium 2400 mg
Potassium 3500 mg
Total Carbohydrate 300 g
Dietary Fiber 25 g
Protein 50 g
Vitamin A 5000 IU
Vitamin C 60 mg
Calcium 1000 mg

Iron 18 mg
Vitamin D 400 IU
Vitamin E 30 IU
Vitamin K 80 µg
Thiamin 1.5 mg
Riboflavin 1.7 mg
Niacin 20 mg
Vitamin B6 2 mg
Folate/Folic Acid 400 µg
Vitamin B12 6 µg
Biotin 300 µg
Pantothenic Acid 10 mg

Phosphorus 1000 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 3400 mg
New Daily Values
Nutrient Original DV

Added sugars –
Choline –
1
%DV in the nutrition facts label will be reflected on January 1, 2020.
Manufacturers with less than $10 million in annual food sales have
until January 1, 2021 to comply.
2
Indicates a unit of measure change.
3
The DV decrease for vitamin E applies for natural forms of vitamin
E in foods/supplements but not for the synthetic form. Food/
supplement containing only the synthetic form of vitamin E, the DV
is increased.
4
The DV decrease for folate/folic acid applies only to foods/
supplements with folic acid or a mixture of folic acid and naturally
occuring folate. The original and updated DV is the same for foods/
supplements containing only naturally occurring folate.
Units of Measure Key:
g = grams
mg = milligrams
µg = micrograms
mg NE = milligrams of niacin equivalents
µg DFE = micrograms of dietary folate equivalents
µg RAE = micrograms of retinol activity equivalents
IU = international units
Source: FDA. (2020). Daily Value on the New Nutrition and

Supplement Facts Labels. https://www.fda.gov/food/new-
nutrition-facts-label/daily-value-new-nutrition-and-supplement-
facts-labels
Figure 12.2 Reading the Older Nutrition Label

Guide for
reading older
Nutrition
Facts label
Adapted from: Image by FDA/Side by Side Comparison of Old and

New Nutrition Facts Label
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: http://www.fda.gov/Food/ResourcesForYou/
Consumers/NFLPM/ucm274593.htm
Original vs. New Format – Infographics to

Help Understand the Changes
Figure 12.3 The Original vs. New Nutrition Facts Label

Image by
FDA/Side by
Side
Comparison
of Old and
New
Nutrition
Facts Label
Figure 12.4 The New Nutrition Facts Label

Image by
FDA/
Changes to
the Nutrition
Facts Label
Figure 12.5 Food Serving Sizes

Image by
FDA/
Changes to
the Nutrition
Facts Label
Source: https://www.fda.gov/Food/GuidanceRegulation/
GuidanceDocumentsRegulatoryInformation/LabelingNutrition/
ucm385663.htm

There are other types of information that are required by law to
1
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
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,
2
and sodium content . The survey also notes that more Americans
1. Food Labeling. US Food and Drug Administration.

https://www.fda.gov/Food/GuidanceRegulation/
GuidanceDocumentsRegulatoryInformation/
LabelingNutrition/ucm385663.htm#highlights. Updated
November 11, 2017. Accessed November 22, 2017.
2. Consumer Research on Labeling, Nutrition, Diet and
Health. US Food and Drug Administration.

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: https://www.fda.gov/food/nutrition-education-
resources-materials/new-nutrition-facts-label
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
3
of cholesterol and two grams of saturated fat . See Table 12.3
“Common Label Terms Defined” for some examples.
Table 12.3 Common Label Terms Defined
https://www.fda.gov/food/foodscienceresearch/
consumerbehaviorresearch/ucm275987.ht. Updated
November 17, 2017.
3. Nutrient Content Claims. US Food and Drug
Administration. https://www.fda.gov/food/
ingredientspackaginglabeling/labelingnutrition/
ucm2006880.htm. Updated December 9, 2014. Accessed
December 10, 2017.

Term Explanation
Fewer than a set amount of grams of fat for that

Lean
particular cut of meat or seafood
High, Rich In,

or Excellent Contains 20% or more of the nutrient’s DV
Source Of
Good source,
Contains or Contains 10 to 19% of the nutrient’s DV
Provides
Contains ⅓ fewer calories or 50% less fat; if more than

Light/lite half of calories come from fat, then fat content must be
reduced by 50% or more
Organic1 Contains 95% certified organic ingredients
1
The term “Organic” is regulated by the USDA and appears as a
USDA Organic Seal in the front of packaged food products,
beverages and dietary supplements
Image by
USDA/
USDA
Organic
Source:

AMS, USDA. https://www.ams.usda.gov/about-ams/programs-
offices/national-organic-program.
Food Labeling Guide. US Food and Drug Administration.
http://www.fda.gov. Updated February 10, 2012. Accessed
November 28, 2017.
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. Implied health claims include the use of
symbols, statements and other forms of communication that
suggest a relationship between a food substance and disease
reduction. As such, health claims such as “Three grams of soluble
fiber from oatmeal daily in combination with a diet low in
cholesterol and saturated fat may reduce the risk of 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 diagnose, mitigate, cure or treat
the disease. For a detailed list of approved health claims, visit:
https://www.fda.gov/food/food-labeling-nutrition/authorized-
health-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. Qualified health claims can be
made for both dietary supplements and conventional food items.
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 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.] Dietary supplements may
declare the amount of EPA and DHA per serving in their section for
“supplement facts” instead.
Soure: FDA (2013). Guidance for Industry: Food Labeling Guide.
http://www.fda.gov/foodlabelingguide
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
4
not evaluated the claim .
4. Claims That Can Be Made for Conventional Foods and

Dietary Supplements. US Food and Drug Administration.
https://www.fda.gov/food/

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 in
Chapter 18 “Nutritional Issues”.) 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.
When Enough Is Enough
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,
ingredientspackaginglabeling/labelingnutrition/
ucm111447.htm. Updated September 2003. Accessed
November 28,2017.

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 2015 Dietary Guidelines a
challenge. In many restaurants and eating establishments, portion
sizes have increased, use of solid fats and added sugars (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 12.6 A Comparison of Serving Sizes
Image by
FDA/
Portion
Distortion
Source: National Heart, Lung, and Blood Institute Obesity Education

Initiative. (2015). Do you know how food portions have changed in
20 years? https://www.nhlbi.nih.gov/health/educational/wecan/
portion/documents/PD1.pdf
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
5
rule .
5. Controlling Portion Sizes. American Cancer Society.

Table 12.4 Determining Food Portions
Object Hand
Food Product Amount
Comparison Comparison
Pasta, rice ½ c. Tennis ball Cupped hand

Fresh vegetables 1 c. Baseball –
Cooked vegetables ½ c. – Cupped hand
Palm of your
Meat, poultry, fish 3 oz. Deck of cards
hand
Milk or other
1 c. Fist –
beverages
Salad dressing 1 Tbsp. Thumb –
Oil 1 tsp. Thumb tip –
Everyday Connections
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.
http://www.cancer.org/Healthy/EatHealthyGetActive/
TakeControlofYourWeight/controlling-portion-sizes.
Updated January 12, 2012. Accessed November 30, 2017.

Eating smaller meals will diminish the size of your appetite
over time so you will feel satisfied with smaller amounts of
food.
Learning Activities

Open Document).






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
1
during the year in 2016 .
1. Food Security in the U.S. United States Department of

Agriculture, Economic Research Service.
https://www.ers.usda.gov/topics/food-nutrition-
assistance/food-security-in-the-us/interactive-charts-
740 | Building Healthy Eating
Patterns
Figure 12.7 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
and-highlights/. Updated September 6, 2017. Accessed

November 22, 2017.
Building Healthy Eating Patterns | 741

support optimal health, the new food plan offers the advice that it is
2
okay to enjoy food, just eat a diverse diet and in moderation .
Image by Got Nutrients?/ Got Nutrients website
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
2. Choose MyPlate. US Department of Agriculture.

http://www.choosemyplate.gov/. Accessed July 22, 2012.
742 | Building Healthy Eating Patterns

Nutrients?” visit, http://www.gotnutrients.net. To receive
the “Daily Tips” by email, visit
http://www.gotnutrients.net/email_alerts/subscribe.cfm
Learning Activities

Open Document).


Building Healthy Eating Patterns | 743


744 | Building Healthy Eating Patterns

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
MyPlate Planner | 745

Building a Healthy Plate: Choose
Nutrient-Dense Foods
Image by
Allison
Calabrese /
CC BY 4.0
Click on the different food groups listed to view their food gallery:
• Fruits
• Grains
• Dairy
• Vegetables
• Protein
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, bok choy, kalo (taro), tomatoes, sweet
746 | MyPlate Planner

potatoes, broccoli, apples, mango, papaya , guavas, 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.
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.
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 fruits in place of foods high
in added sugars, saturated fats, and sodium 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.
Starting with these small shifts in your diet as mentioned above 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. See Table 12.5 “Sample
Menu Plan Containing 2,000 Calories”. 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
1
sugar or honey to cereal, or consuming an alcoholic beverage .
1. US Department of Agriculture. MyPyramid Education

Framework. Accessed July 22, 2012.

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 12.5 Sample Menu Plan Containing 2,000 Calories

Total Meal/Snack
Meal Calories
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

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
(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 Dietary

Guidelines, the Center for Nutrition Policy and Promotion (CNPP),
a division of the USDA, uses a standardized tool called the Healthy
2
Eating Index (HEI) .
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
2. Healthy Eating Index. US Department of Agriculture.

http://www.cnpp.usda.gov/healthyeatingindex.htm.
Updated March 14, 2012. Accessed November 22, 2017.

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: http://www.cnpp.usda.gov/
healthyeatingindex.htm.
The Whole Nutrient Package versus Disease
A healthy diet incorporating seven or more servings of fruits and

vegetables has been shown in many scientific studies to reduce
cardiovascular disease and overall deaths attributable to cancer.
The WHO states that insufficient fruit and vegetable intake is linked
to approximately 14 percent of gastrointestinal cancer deaths, about
11 percent of heart attack deaths, and 9 percent of stroke deaths
3
globally .
The WHO estimates that, overall, 2.7 million deaths could be
avoided annually by increasing fruit and vegetable intake. These
preventable deaths place an economic, social, and mental burden on
3. Global Strategies on Diet, Physical Activity, and Health.

World Health Organization. http://www.who.int/
dietphysicalactivity/fruit/en/index.html. Accessed
September 30, 2011.

society. This is why, in 2003, the WHO and the Food and Agricultural
Organization of the United Nations launched a campaign to
promote fruit and vegetable intake worldwide.
Antioxidant Variety in Food Provides

Health Benefits
Not only has the several-billion-dollar supplement industry

inundated us with FDA-unapproved health claims, but science is
continuously advancing and providing us with a multitude of
promising health benefits from particular fruits, vegetables, teas,
herbs, and spices. For instance, blueberries protect against
cardiovascular disease, an apple or pear a day reduces stroke risk by
over 52 percent, eating more carrots significantly reduces the risk of
bladder cancer, drinking tea reduces cholesterol and helps glucose
homeostasis, and cinnamon blocks infection and reduces the risk of
some cancers. However, recall that science also tells us that no one
nutrient alone is shown to provide these effects.
What micronutrient and phytochemical sources are best at
protecting against chronic disease? All of them, together. Just as
there is no wonder supplement or drug, there is no superior fruit,
vegetable, spice, herb, or tea that protects against all diseases. A
review in the July–August 2010 issue of Oxidative Medicine and
Cellular Longevity concludes that the plant-food benefits to health
are attributed to two main factors—that nutrients and
phytochemicals are present at low concentrations in general, and
that the complex mixtures of nutrients and phytochemicals
4
provides additive and synergistic effects . In short, don’t overdo it
4. Bouayed, J. and T. Bohn. (2010). Exogenous

Antioxidants—Double-Edged Swords in Cellular Redox

with supplements and make sure you incorporate a wide variety of
nutrients in your diet.
Eating a variety of fruits and vegetables rich in antioxidants and
phytochemicals promotes health. Consider these diets:
Mediterranean diet. Fresh fruit and vegetables are abundant in this
diet, and the cultural identity of the diet involves multiple herbs
and spices. Moreover, olive oil is the main source of fat. Fish and
poultry are consumed in low amounts and red meat is consumed
in very low amounts. An analysis of twelve studies involving over
one million subjects published in the September 2008 issue of the
British Medical Journal reports that people who followed the
Mediterranean diet had a 9 percent decrease in overall deaths, a 9
percent decrease in cardiovascular death, a 6 percent decrease in
cancer deaths, and a 13 percent reduced incidence of Parkinson’s
5
disease and Alzheimer’s disease . The authors of this study
concluded that the Mediterranean diet is useful as a primary
prevention against some major chronic diseases.
Dietary Approaches to Stop Hypertension (DASH diet). Recall
from Chapter 7 “Nutrients Important to Fluid and Electrolyte
Balance” that the DASH diet is an eating plan that is low in saturated
fat, cholesterol, and total fat. Fruits, vegetables, low-fat dairy foods,
State: Health Beneficial Effects at Physiologic Doses

versus Deleterious Effects at High Doses. Oxidative
Medicine and Cellular Longevity, 3(4), 228–37.
PMC2952083/?tool=pubmed. Accessed November 22,
2017.
5. Sofi F, et al. (2008). Adherence to Mediterranean Diet
and Health Status: Meta-Analysis. British Medical
Journal, 337, a1344. http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC2533524/. Accessed November 22, 2017.

whole-grain foods, fish, poultry, and nuts are emphasized while red
meats, sweets, and sugar-containing beverages are mostly avoided.
Results from a follow-up study published in the December 2009
issue of the Journal of Human Hypertension suggest the low-
sodium DASH diet reduces oxidative stress, which may have
contributed to the improved blood vessel function observed in salt-
6
sensitive people (between 10 to 20 percent of the population) .
Diets high in fruits and vegetables. An analysis of The Nurses’
Health Study and the Health Professionals’ Follow-up Study
reported that for every increased serving of fruits or vegetables
per day, especially green leafy vegetables and vitamin C-rich fruits,
7
there was a 4 percent lower risk for heart disease .
6. Al-Solaiman Y, et al. (2008). Low-Sodium DASH Reduces

Oxidative Stress and Improves Vascular Function in Salt-
Sensitive Humans. Journal of Human Hypertension, 12,
2017.
7. Joshipura KJ, et al. (2001). The Effect of Fruit and
Vegetable Intake on Risk for Coronary Heart Disease.
Annuals of Internal Medicine, 134(12), 1106–14.

Americans Typically Eat Fewer than the
Recommended Servings of High Quality
Food-Group Foods
An article in the January 2009 issue of the Medscape Journal of

Medicine reports that fewer than one in ten Americans consumes
the recommended amount of fruits and vegetables, which is
8
between five and thirteen servings per day . According to this
study, the largest single contributor to fruit intake was orange juice,
and potatoes were the dominant vegetable.
The USDA recommends that you fill half your plate with fruits
and vegetables. The number of servings of fruits and vegetables
that a person should consume every day is dependent on age, sex,
and level of physical activity. For example, a forty-year-old male
who exercises for sixty minutes per day should consume 2 cups of
fruit and 3½ cups of vegetables, while a fifteen-year-old female who
exercises for thirty minutes per day should consume 1½ cups of fruit
and 2½ cups of vegetables. (One cup of a fruit or vegetable is equal
to one banana, one small apple, twelve baby carrots, one orange,
or one large sweet potato.) To find out the amount of fruits and
vegetables the Centers for Disease Control and Prevention (CDC)
recommends, see Note 8.25 “Interactive 8.4”.
8. Kimmons J, et al. (2009). Fruit and Vegetable Intake

among Adolescents and Adults in the United States:
Percentage Meeting Individualized Recommendations.
Medscape Journal of Medicine, 11(1), 26.
2017.

Improving Fruit and Vegetable Intake at
Home and in Your Community
Eating more fruits and vegetables can make you think better, too.
According to a study published in 2009 in the Journal of Alzheimer’s
Disease, no matter your age, eating more fruits and vegetables
9
improves your brain function . Check out Note 8.26 “Interactive 8.5”
for thirteen fun ways to increase your fruit and vegetable intake.
The CDC has developed seven strategies to increase American’s
10
intake of fruits and vegetables .
1. Support local and state governments in the implementation of

a Food Policy Council, which develops policies and programs
that increase the availability of affordable fruits and vegetables.
2. In the food system, increase the availability and affordability of
high-quality fruits and vegetables in underserved populations.
3. Promote farm-to-where-you-are programs, which is the
9. Polidori MC, et al. (2009). High Fruit and Vegetable

Intake Is Positively Correlated with Antioxidant Status
and Cognitive Performance in Healthy Subjects. Journal
of Alzheimer’s Disease, 17(4), 921–7.
10. The CDC Guide to Fruit and Vegetable Strategies to
Increase Access, Availability, and Consumption. Centers
for Disease Control and Prevention.
http://www.cdph.ca.gov/SiteCollectionDocuments/
StratstoIncreaseFruitVegConsumption.pdf. Updated
March 2010. Accessed November 22, 2017.

delivery of regionally grown farm produce to community
institutions, farmers markets, and individuals.
4. Encourage worksites, medical centers, universities, and other
community and business establishments to serve more fruits
and vegetables in cafeterias and onsite eateries.
5. Support schools in developing healthy food messages to
students by incorporating activities such as gardening into
curricula.
6. Encourage the development and support of community and
home gardens.
7. Have emergency food programs, including food banks and food
rescue programs, increase their supply of fruits and vegetables.
The seven strategies developed by the CDC are based on the idea
that improving access to and availability of fruits and vegetables will
lead to an increase in their consumption.
Learning Activities

Open Document).




Pacific Based Dietary
Guidelines
To reflect the unique food environment and practices of the Pacific,

the Secretariat of the Pacific Community (SPC) Public Health
division developed Dietary Guidelines for healthy eating to promote
1
and protect the health and future of Pacific Island peoples . With
such a diverse food supply, it can be difficult to place some pacific
foods into the USDA 5 food group system. For example, ‘ulu,
otherwise known as breadfruit, is a fruit but also has many similar
properties and functions like whole grains as well due to its high
carbohydrate and fiber content.
Therefore, guidelines for healthy eating include a series of leaflets
and fact sheets that focus on traditional Pacific foods, food security,
and health issues in the Pacific region. Healthy eating guidelines for
2
adults and children are divided into 3 main food groups .
1. Factsheet no. 16 – Healthy Eating. Secretariat of the

Pacific Community. https://www.spc.int/hpl/
index2.php?option=com_docman&task=doc_view&gid=
58&Itemid=51. Published 2002. Accessed December 2,
2017.
2. Factsheet no. 9 – Feeding babies and young children.
Secretariat of the Pacific Community.
http://www.spc.int/hpl/
index2.php?option=com_docman&task=doc_view&gid=
760 | Pacific Based Dietary
Guidelines
Table 12.6 The Different Categories from the Pacific
Energy
Body-building
Nutrient-dense Protective Foods
Foods
foods
Foods that are
Types of both high in Protein-rich
Fruits and vegetables
Foods calories and high foods
in nutrients
The
The foods in this
recommendation The foods in
group are high in
is that these foods this group are
vitamins and minerals.
should be high in
These foods are
included in all protein and is
recommended to be
Description meals recommended
included in all meals
contributing to to be eaten
and snacks
about half of the twice a day in
contributing about
food you small
one third of the food
consume each amounts.
consumed each day.
day.
The recommendation is that these foods should be included in all

meals contributing to about half of the food you consume each day.
The foods in this group are high in vitamins and minerals. These
foods are recommended to be included in all meals and snacks
contributing about one third of the food consumed each day. The
foods in this group are high in protein and is recommended to be
eaten twice a day in small amounts. Examples of each of the foods
from the Pacific that fit into these categories are shown in the image
below.
Figure 12.8 Healthy Eating in the Pacific
51&Itemid=51. Published 2002. Accessed December 2,

2017.
Pacific Based Dietary Guidelines | 761

Secretariat
of the Pacific
Community
/ CC
BY-NC-ND
4.0
The overall key messages to the SPC Dietary Guidelines are to

consume a variety of foods each day from the 3 food groups.
However, food should be consumed in moderation as too much
of any one food can be unhealthy. Foods should be consumed in
recommended amounts. In addition, every effort should be made to
consuming foods that are locally sourced. See the image below for a
depiction of the key messages of the SPC Dietary Guidelines.
Figure 12.9 The Pacific Guide to Healthy Eating
762 | Pacific Based Dietary Guidelines

Secretariat
of the Pacific
Community
/ CC
BY-NC-ND
4.0
To learn more about the SPC visit http://www.spc.int/about-us/
Bridging MyPlate with the Pacific
Although the diversity and expansiveness of the Pacific region

makes this a monumental task, a food guide that reflects the
traditional foods of the Pacific in relation to the US Dietary

Guidelines, more specifically MyPlate, was needed. The Pacific Food
Guide was developed by the Children’s Healthy Living Program
(CHL) for Remote and Underserved Minorities of the Pacific Region.
CHL is a partnership among the remote Pacific jurisdictions of
Alaska, American Samoa, CNMI, RMI, the Republic of Palau, FSM,
Guam, and Hawai‘i to study child obesity among Pacific children,
ages 2-8 years. The program is sponsored by the United States
Department of Agriculture (USDA), Agriculture and Food Research
Initiative Grant no 2011-68001-30335. To learn more about CHL
visit http://www.chl-pacific.org/. The Pacific Food Guide is freely
available at
http://manoa.hawaii.edu/ctahr/pacificfoodguide/index./about-
the-guide/
Developed to assist with teaching introductory nutrition at the
University of Hawai‘i at Mānoa, the Pacific Food Guide allows
readers to explore the traditional foods of the Pacific in relation to
both dietary guideline systems (USDA and SPC). Since foods of the
Pacific cross over multiple categories of both the MyPlate and SPC
Dietary Guidelines foods are organized into 3 neutral categories:
• Walks along the Ground (animals)

• Chosen from the Sea (seafood)
• Grown from the Ground (plants)
The Pacific Food Guide allows users to identify with the origin of
specific Pacific foods and see how these foods fit into both dietary
guidelines using a unique set of pins (see image below). By grouping
foods into its origin it allows for readers who may not be familiar
with either/neither dietary guidelines to use the Guide.

These pins label foods according to the USDA MyPlate guidelines
and food groups.
These pins label foods according to the SPC food groups for
healthy eating in the Pacific.

Note: There may be a few foods that do not fall in either of the
3 food groups, which the SPC regards as not essential or needed
in significant amounts to achieve healthy eating. The
recommendations for these miscellaneous food items are to “Eat
Less” of, but not necessarily to avoid completely as they may have
cultural and traditional value. Such food items will have this pin.
To learn more about how to use the Pacific Food Guide visit
http://manoa.hawaii.edu/ctahr/pacificfoodguide/index.php/
nutritional-guidelines/how-to-use-the-guide/
Learning Activities

Open Document).



Understanding the Bigger
Picture of Dietary Guidelines
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.
Establishing Human Nutrient

Requirements for Worldwide Application
The Department of Nutrition for Health and Development, in
768 | Understanding the Bigger

Picture of Dietary Guidelines
collaboration with FAO, continually reviews new research and
information from around the world on human nutrient
requirements and recommended nutrient intakes. This is a vast
and never-ending task, given the large number of essential human
nutrients. These nutrients include protein, energy, carbohydrates,
fats and lipids, a range of vitamins, and a host of minerals and trace
elements.
Many countries rely on WHO and FAO to establish and
disseminate this information, which they adopt as part of their
national dietary allowances. Others use it as a base for their
standards. The establishment of human nutrient requirements is the
common foundation for all countries to develop food-based dietary
guidelines for their populations.
Establishing requirements means that the public health and
clinical significance of intake levels – both deficiency and excess
– and associated disease patterns for each nutrient, need to be
thoroughly reviewed for all age groups. Every ten to fifteen years,
enough research is completed and new evidence accumulated to
warrant WHO and FAO undertaking a revision of at least the major
nutrient requirements and recommended intakes.
http://www.who.int/nutrition/topics/nutrecomm/en/
Why Are Guidelines Needed?
Instituting nation-wide standard policies provides consistency

across organizations and allows health-care workers, nutrition
educators, school boards, and eldercare facilities to improve
nutrition and subsequently the health of their respective
populations. At the same time, the goal of the Dietary Guidelines
is to provide informative guidelines that will help any interested
person in obtaining optimal nutritional balance and health. The
seventh edition of the Dietary Guidelines was released in 2010 and
focused mainly on combating the obesity epidemic. USDA secretary
Understanding the Bigger Picture of Dietary Guidelines | 769

Tom Vilsack says, “The bottom line is that most Americans need to
trim their waistlines to reduce the risk of developing diet-related
chronic disease. Improving our eating habits is not only good for
every individual and family, but also for our country.” The 2015
Dietary Guidelines focus on eating patterns, which may be
predictive of overall health status and disease risk. The Dietary
Guidelines were formulated by the Food and Nutrition Board of
the Institute of Medicine (IOM), which has recently changed their
name to the National Academy of Medicine (NAM). These guidelines
are from the review of thousands of scientific journal articles by
a consensus panel consisting of more than two thousand nutrition
experts with the overall mission of improving the health of the
1
nation .
Major Themes of the 2015 Dietary

Guidelines
Consume a healthy eating pattern that accounts for all foods and
1. Johnson TD. (2011). New Dietary Guidelines Call for Less

Salt, Fewer Calories, More Exercise. Nation’s Health,
41(2), E6. http://thenationshealth.aphapublications.org/
content/41/2/E6.full. Accessed November 22, 2017. Key
Recommendations: Components of Healthy Living
Patterns. Dietary Guidelines 2015-2020.
https://health.gov/dietaryguidelines/2015/guidelines/
chapter-1/key-recommendations/. Published 2015.
770 | Understanding the Bigger Picture of Dietary Guidelines

beverages within an appropriate calorie level. A healthy eating
2
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
A healthy eating pattern limits:
• Saturated fats and trans fats, added sugars, and sodium

• Cholesterol, in order to limit saturated fats.
Previously, the recommendation for cholesterol was less than 300

mg/day of cholesterol for the general public, and less than 200
mg/day for those with cardiovascular disease risk. The 2015 Dietary
Guidelines recommends consuming as little dietary cholesterol as
possible rather than quantifying it because someone consuming
a diet according to the recommendations would consume around
100-300 mg daily and because dietary cholesterol does not impact
2. Key Recommendations: Components of Healthy Living


3
blood cholesterol levels as much as previously believed . The reason
for consuming as little cholesterol as possible is because many (but
not all) foods that have cholesterol also have saturated fat.
Key Recommendations that are quantitative are provided for
several components of the diet that should be limited. These
components are of particular public health concern in the United
States, and the specified limits can help individuals achieve healthy
eating patterns within calorie limits:
• 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
4
men—and only by adults of legal drinking age .
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.
The average person consumes 3,400 milligrams of sodium per
day, mostly in the form of table salt. The 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. The Dietary Guidelines stress 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 should be
5
consumed in moderation in a healthy diet .
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 Dietary Guidelines provide the following suggestions on food
choices to achieve a healthier diet:
5. Nelson, J. and K. Zeratsky. Dietary Guidelines Connect

SoFAS and Weight Gain. Mayo Clinic, Nutrition-Wise
(blog). http://www.mayoclinic.com/health/dietary-
guidelines/MY01417. Published August 25, 2010.

Instead of… Replace with…
Sweetened fruit
Plain fat-free yogurt with fresh fruit
yogurt
Whole milk Low-fat or fat-free milk
Cheese Low-fat or reduced-fat cheese
Bacon or sausage Canadian bacon or lean ham
Sweetened
Minimally sweetened cereals with fresh fruit
cereals
Apple or berry
Fresh apple or berries
pie
Deep-fried
Oven-baked French fries or sweet potato baked fries
French fries
Fried vegetables Steamed or roasted vegetables

Sugary
sweetened soft Seltzer mixed with 100 percent fruit juice
drinks
Recipes that call Experiment with reducing amount of sugar and
for sugar adding spices (cinnamon, nutmeg, etc…)
Source: Food Groups. US Department of Agriculture.

http://www.choosemyplate.gov/food-groups/. Updated April 19,
2017. Accessed November 22, 2017.
Learning Activities


Open Document).



PART XIII
CHAPTER 13. LIFESPAN
NUTRITION FROM
PREGNANCY TO THE
TODDLER YEARS
Chapter 13. Lifespan Nutrition From

Pregnancy to the Toddler Years | 777
Introduction
I maika‘i ke kalo i ka ‘ohā
The goodness of the taro is judged by the young plant it

produces
Image by Pua
O Eleili Pinto
/ CC BY 4.0
Introduction | 779
Learning Objectives
• Describe the physiological basis for nutrient

requirements from pregnancy through the toddler
years.
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
1
and setting up lifelong health.
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,
1. Pukai MK., Handy ESC. (1958). The Polynesian Family

System in Ka-‘u. Rutland, Vermont: Charles E. Tuttle
Company
780 | Introduction
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.
Figure 13.1 Ultrasound image of a four-month-old fetus.
Introduction | 781
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
2
for life outside of the womb. Journey Across the LifeSpan: Human
Development and Health Promotion. Philadelphia: F.A. Davis
Company, 81–82. The ability to coordinate sucking and swallowing,
2. Polan EU, Taylor DR. (2003),
782 | Introduction
necessary for feeding at birth, is not present until 32-34 weeks, and
3
matures around 36-38 weeks gestation.
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.
Learning Activities

Open Document).

3. Stanford Children’s Health. (n.d.). Retrieved June 9, 2020,

from https://www.stanfordchildrens.org/en/topic/
default?id=newborn-reflexes-90-P02630
Introduction | 783
784 | Introduction
Pregnancy
Image by
Marie
Kainoa
Fialkowski
Revilla / CC
BY 4.0
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
Pregnancy | 785
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.
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
1
alcohol may also damage the quantity and quality of their sperm. .
For both men and women, adopting healthy habits also boosts
general well-being and makes it possible to meet the demands of
parenting.
1. Healthy Sperm: Improving Your Fertility. Mayo Clinic.

1998–2012 Mayo Foundation for Medical Education and
Research. http://www.mayoclinic.com/health/fertility/
MC00023. Accessed February 21, 2012.
786 | Pregnancy
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
Image by Centers for Disease pregnancy and 600
Control and Prevention (CDC) / micrograms per day
Public Domain
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
Pregnancy | 787
oranges. Additionally, since 1998, food manufacturers
have been required to add folate to cereals and other
2
grain products.
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 13.1 “Body
Mass Index and Pregnancy” for The Institute of Medicine (IOM)
recommendations.
2. Folic Acid. MedlinePlus, a service of the National

Institutes of Health. 1995–2012 http://www.nlm.nih.gov/
medlineplus/druginfo/natural/1017.html. Updated
August 7, 2011. Accessed November 22, 2017.
788 | Pregnancy
3
Table 13.1 Body Mass Index and Pregnancy
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
3. Weight Gain during Pregnancy: Reexamining the

Guidelines. Institute of Medicine. https://www.nap.edu/
resource/12584/Report-Brief---Weight-Gain-During-
Pregnancy.pdf
Pregnancy | 789
with more than one fetus are advised to gain even more weight to
ensure the health of their unborn babies.
Figure 13.2 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
4
retain water .
4. Weight Gain during Pregnancy. Utah Department of

Health, Baby Your Baby. http://www.babyyourbaby.org/
790 | Pregnancy
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
5
of the extra weight, although research is ongoing. .
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.
pregnancy/during. 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.
Pregnancy | 791
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
792 | Pregnancy
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.
Pregnancy | 793
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.
http://www.womenshealth.gov/pregnancy/you-are-pregnant/
body-changes -discomforts.cfm. 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 13.2 Recommended Nutrient Intakes during Pregnancy
794 | Pregnancy
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. http://iom.edu/
Reports/1990/Nutrition-During-Pregnancy-Part-I-Weight-Gain-
Part-II-Nutrient-Supplements.aspx. Published January 1, 1990.
Vitamins:
https://www.ncbi.nlm.nih.gov/books/NBK56068/table/
summarytables.t2/?report=objectonly. Published by the National
Academies Press; 2011. Accessed April 25, 2020.
Minerals:
https://www.ncbi.nlm.nih.gov/books/NBK545442/table/
appJ_tab3/?report=objectonly. 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
Pregnancy | 795
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.
Guide to Eating during Pregnancy
While pregnant women have an increased need for energy, vitamins,
796 | Pregnancy
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.
6
Here are some additional dietary guidelines for pregnant women. :
• 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.
6. Staying Healthy and Safe. US Department of Health and

Human Services, Office on Women’s Health. Last
updated March 5, 2009.
https://www.womenshealth.gov/pregnancy/youre-
pregnant-now-what/staying-healthy-and-safe. Updated
February 1, 2017. Accessed November 30, 2017.
Pregnancy | 797
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 13.3 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
798 | Pregnancy
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
7
miscarriage .
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
8
(about one 8-ounce cup of coffee a day or less) . However, that
amount should not be exceeded.
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
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.
Pregnancy | 799
fever. If the infection spreads to the nervous system, it can result in
9
a stiff neck, convulsions, or a feeling of disorientation .
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
9. Listeria and Pregnancy. American Pregnancy

Association. http://www.americanpregnancy.org/
pregnancycomplications/listeria.html. Updated March
10, 2017. Accessed November 29, 2017.
800 | Pregnancy
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 http://www.edf.org. 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:
https://health.hawaii.gov/wic/files/2019/05/A-Local-Guide-to-
Eating-Fish-Safely_2019-update.pdf. 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
10
and the 2018 Physical Activity Guidelines for Americans . Regular
exercise of moderate intensity, about thirty minutes per day most
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
Pregnancy | 801
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
11
quickly .
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
11. Reid, R. L., & Lorenzo, M. (2018). SCUBA Diving in

Pregnancy. Journal of Obstetrics and Gynaecology
Canada, 40(11), 1490–1496. https://doi.org/10.1016/
j.jogc.2017.11.024)
802 | Pregnancy
to indulge in the occasional craving, such as the desire 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
Pregnancy | 803
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
12
development of pre-eclampsia and its complications .
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
13
Type 2 diabetes later in life, particularly if they are overweight. .
12. WHO Recommendations for Prevention and Treatment

of Pre-eclampsia and Eclampsia.World Health
Organization. http://whqlibdoc.who.int/publications/
2011/9789241548335_eng.pdf. Published 2011. Accessed
June 9, 2020.
13. Noctor, E., & Dunne, F. P. (2015). Type 2 diabetes after
804 | Pregnancy
Learning Activities

Open Document).


gestational diabetes: The influence of changing

diagnostic criteria. World Journal of Diabetes, 6(2),
234–244. https://doi.org/10.4239/wjd.v6.i2.234.
Pregnancy | 805
806 | Pregnancy
Infancy
Image by
Marie
Kainoa
Fialkowski
Revilla / CC
BY 4.0
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
Infancy | 807
is making sure that children receive an adequate amount of needed
nutrients to provide a strong foundation for the rest of their lives.
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
1
babies start out being breastfed. 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
2
Disease Control and Prevention (CDC).
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
1. U.S. Centers for Disease Control. (2018). Breastfeeding

report card United States, 2018. https://www.cdc.gov/
breastfeeding/pdf/2018breastfeedingreportcard.pdf
2. U.S. Centers for Disease Control. (2018). Breastfeeding
report card United States, 2018. https://www.cdc.gov/
breastfeeding/pdf/2018breastfeedingreportcard.pdf
808 | Infancy
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
3
staff.
Other important practices for maternity hospitals to support
breastfeeding are summarized in the Ten Steps to Successful
4
Breastfeeding, launched jointly by the WHO and UNICEF. 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.
3. US Department of Health and Human Services. (2011,

January 20). Executive summary: The Surgeon General’s
call to action to support breastfeeding.
http://www.surgeongeneral.gov/topics/breastfeeding/
executivesummary.pdf
4. Baby-Friendly USA. (2020). The ten steps to successful
breastfeeding. https://www.babyfriendlyusa.org/for-
facilities/practice-guidelines/10-steps-and-
international-code/
Infancy | 809
Employment can also factor into a woman’s decision to breastfeed
or 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
5
break time for a woman to express milk. 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
6
the employee breastfeeds or expresses milk at the workplace, and
the right for breastfeeding mothers to decline jury duty until the
5. US Department of Health and Human Services. (2011,

January 20). Executive summary: The Surgeon General’s
call to action to support breastfeeding.
http://www.surgeongeneral.gov/topics/breastfeeding/
executivesummary.pdf
6. US Legal, Inc. (2019). Hawaii.
https://breastfeedinglaws.uslegal.com/state-laws/
hawaii-breast-feeding-laws/
810 | Infancy
7
child is 1 year old. See: https://wicworks.fns.usda.gov/resources/
50-state-summary-breastfeeding-laws
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
http://health.hawaii.gov/wic/files/2013/04/
WorkplaceBreastfeeding_02_2014.pdf and for Guam’s laws
visit http://www.guamcourts.org/CompilerofLaws/GCA/
10gca/10gc092A.pdf.
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
7. Hawaiʻi State Judiciary. (2020). Jury service frequently

asked questions. https://www.courts.state.hi.us/
general_information/jury/jury_service_faqs#Q9
Infancy | 811
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
http://www.llli.org. The state coalition, Breastfeeding Hawai‘i,
provides a list of local and national resources: https://bfhawaii.org/
index.php/lactation-support/.
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.
812 | Infancy
Infancy (Birth to Age One)
Image by
Marie
Kainoa
Fialkowski
Revilla / CC
BY 4.0
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
Infancy | 813
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
8
nutrition to ensure development at the appropriate rate.
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.
Figure 13.4 WHO Growth Chart For Boys From Birth To 24 Months
8. McMillan B. (2008). Illustrated atlas of the human body.

Weldon Owen.
814 | Infancy
Image by
Centers for
Disease
Control and
Prevention /
Public
Domain
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
are entirely dependent on their parents or other caregivers to meet
these needs. For almost all infants six months or younger, breast
Infancy | 815
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
9
longer.
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
9. World Health Organization. (2019). Promoting proper

feeding for infants and young children.
https://www.who.int/nutrition/topics/infantfeeding/
en/
816 | Infancy
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
10
per day for girls. 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
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.
Infancy | 817
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
11
milk is also low in vitamin K Pediatric clinics of North America, 60(1),
49–74., 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
11. Ballard, O., & Morrow, A. L. (2013). Human milk

composition: nutrients and bioactive factors.
818 | Infancy
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.
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.
Infancy | 819
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.
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
820 | Infancy
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.
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
Infancy | 821
successful. Around the world, approximately 40 percent of infants
121314
are breastfed exclusively for the recommended 6 months.
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
12. UNICEF Data. (2019, October). Infant and young child

feeding. https://data.unicef.org/topic/nutrition/infant-
and-young-child-feeding/
13. UNICEF. For every child, breastfeeding.
https://www.unicef.org/breastfeeding/
14. FAO, IFAD, UNICEF, WFP and WHO. (2019). The state of
food security and nutrition in the world 2019.
http://www.fao.org/3/ca5162en/ca5162en.pdf
822 | Infancy
inhibits milk secretion. Shortly after birth, the expulsion of the
placenta triggers progesterone levels to fall, which activates
15
lactation. 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
15. King J. (2007). Contraception and lactation: Physiology

of lactation. Journal of Midwifery and Women’s Health,
52(6), 614–20.
Infancy | 823
compares the recommended vitamins and minerals for lactating
women to the levels for nonpregnant and pregnant women.
Table 13.3 Recommended Nutrient Intakes during Lactation
824 | Infancy
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
Infancy | 825
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
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. https://www.nap.edu/catalog/11537/dietary-reference-
intakes-the-essential-guide-to-nutrient-requirements
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.
826 | Infancy
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
16
and protect the baby from bacterial and viral diseases. 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
16. American Pregnancy Association. (2019, October 14).

Breastfeeding: Overview.
http://www.americanpregnancy.org/firstyearoflife/
breastfeedingoverview.htm.
Infancy | 827
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
17
of liquid secreted.
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
18
develop properly.
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

828 | Infancy
(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.
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
Infancy | 829
19
a woman’s body weight. 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
20
ongoing in these areas.
Breastfeeding has a number of other important benefits. It is
19. LaFleur, E. (2019, July 3). Breast-feeding and alcohol: Is it

okay to drink?. Mayo Clinic.
http://www.mayoclinic.com/health/breast-feeding-
and-alcohol/AN02131.
20. American Academy of Pediatrics. (2016, August 8).
Breastfeeding benefits your baby’s immune system.
http://www.healthychildren.org/English/ages-stages/
baby/breastfeeding/pages/Breastfeeding-Benefits-
Your-Baby%27s-Immune-System.aspx
830 | Infancy
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
21
that breastfeeding reduces the risk of breast and ovarian cancers.
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
21. National Cancer Institute. (2016, November 9).

Reproductive history and breast cancer risk.
http://www.cancer.gov/cancertopics/factsheet/Risk/
reproductive-history.
Infancy | 831
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
22
developed world and in developing nations. For
information on the Baby-Friendly Initiative in the US, see:
https://www.babyfriendlyusa.org.
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.
One of the first challenges nursing mothers face is learning how
22. UNICEF. The baby-friendly hospital initiative.

http://www.unicef.org/programme/breastfeeding/
baby.htm
832 | Infancy
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: https://lllusa.org/lie-back-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: https://wicworks.fns.usda.gov/resources/50-state-
summary-breastfeeding-laws.
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
Infancy | 833
their infants while taking antiretroviral medications to lower the
23
risk of transmission. 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
24
thirty- to sixty-thousand newborns. 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
23. World Health Organization. (2020, April 1). Infant and

young child feeding. http://www.who.int/mediacentre/
factsheets/fs342/en/index.html
24. Genetics Home Reference. (2020, June 9)
Galactosemia. http://ghr.nlm.nih.gov/condition/
galactosemia
834 | Infancy
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.
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
Infancy | 835
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 13.4 Breast Milk versus Bottle Formula
836 | Infancy
Breast Milk Bottle Formula
Antibodies and lactoferrin in breast Formula does not contain

milk protect infants. immunoprotective factors.
The iron in breast milk is absorbed Formula contains more iron
more easily. Because the iron is bound than breast milk, but it is not
to lactoferrin, it is not available for absorbed as easily, and the iron
bacteria in the gut to use as a growth is a growth factor for pathogenic
factor. microbes.
The feces that babies produce do not The feces that bottle-fed infants
smell because breastfed infants have produce tends to have a
different bacteria in the gut. foul-smelling odor.
Formula must be prepared,
Breast milk is always available and is refrigerated for storage, and
always at the correct temperature. warmed before it is given to an
infant.
Breastfed infants are less likely to Bottle-fed infants are more
have constipation. likely to have constipation.
Breastfeeding ostensibly is free,
Formula must be purchased and
though purchasing optional supplies
is expensive, typically costing
such as a pump and bottles to express
over $1,200 in the first year.
milk does require some expense.
Breast milk contains the fatty acids
Some formulas contain DHA and
DHA and EPA, which are vital for brain
EPA.
and vision development.
Source: American Pregnancy Association (2019, October 14).

Breastfeeding versus bottle feeding.
breastfeedingandbottle.html
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,
Infancy | 837
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.
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: https://wicworks.fns.usda.gov/
resources/infant-nutrition-and-feeding-guide.
Everyday Connection
Different cultures have specific food customs. In ancient
838 | Infancy
Hawai‘i, poi (pounded taro) was a staple food in the diet and
is still popular today due to it’s nutrient-dense structure.
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.
Infancy | 839
Complementary Foods
Guidelines for feeding healthy infants from the USDA Infant

Nutrition and Feeding Guidelines are adapted in the table below.
Table 13.5 Guidelines for Feeding Healthy Infants Birth to 12
Months Old
840 | Infancy
Human Milk or Grain Protein-rich
Age Vegetables Fruit
infant formula products foods
Newborns
breastfeed 8-12
times/day.
Formula fed
infants should
Birth –
consume 2-3
6 None None None None
ounces of
months
formula every
3-4 hours and
by 6 months
consume 32
ounces/day.
Breastfed
infants
continue to
breastfeed, on
demand. About 1-2
ounces
Formula-fed About 1-2 About 2-4 meat,
About 2-4
infants take in ounces ounces of poultry,
ounces of
about 24-32 iron-fortified cooked, fish, eggs,
plain
6-8 ounces. infant plain, cheese,
strained/
months Amounts vary cereals, strained/ yogurt, or
pureed/
based on bread, small pureed/ legumes; all
mashed
individual pieces of mash are plain
fruits
assessment. crackers vegetables strained/
Intake of pureed/
human milk or mashed
formula may
decrease as
complementary
foods increase.
Infancy | 841
Guide/
encourage
breastfeeding
mothers and
About 2-4
continue to About 2-4
ounces
support ounces
meat,
mothers who iron-fortified
poultry,
choose to infant
About 4-6 About 4-6 fish, eggs,
breastfeeding cereals;
ounces, ounces, cheese,
beyond 12 other grains:
8-12 ground/ ground/ yogurt, or
months. baby
months finely finely mashed
crackers,
chopped/ chopped/ legumes; all
Formula-fed bread,
diced diced are
infants take in noodles,
ground/
about 24 corn, grits,
finely
ounces. soft tortilla
chopped/
Amounts vary pieces
diced
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. https://www.healthychildren.org/
English/ages-stages/baby/formula-feeding/Pages/Amount-and-
Schedule-of-Formula-Feedings.aspx
Leonberg, B. L. (2020). Pocket guide to pediatric nutrition
assessment, 2nd ed. Academy of Nutrition and Dietetics.
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.
842 | Infancy
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 13.6 Common Foods That Cause Choking in Children Under
Age 4
Infancy | 843
Protein-rich Grain Other foods
Vegetables Fruits
foods products and snacks
Tough or
large chunks
Small pieces of meat
of raw
Apples or
vegetable Hot dogs,
other hard Hard or round
(like raw meat sticks,
pieces of candy
carrot or sausages
raw fruit,
rounds, (even when
especially Jelly beans
baby cut into
those with Caramels
carrots, round slices)
hard pits or Plain wheat Gum drops,
string Fish with
seeds germ gummy
beans, or bones
candies, or
celery), or Large
Large, hard Whole-grain other gooey
other raw, chunks of
pieces of kernels or sticky
partially cheese or
uncooked Crackers candy
cooked string
dried fruits or breads Chewy fruit
vegetables cheese
Whole with seeds snacks
Peanuts,
pieces of Nut Chewing
Raw green nuts, or
canned fruit pieces gum
peas seeds (like
Whole Hard Marshmallo
Cooked or sunflower or
grapes, pretzels ws
uncooked pumpkin
cherries, Popcorn,
whole corn seeds)
berries, potato or
kernels Chunks or
melon balls, corn chips, or
Large, spoonfuls of
or cherry similar snack
hard pieces peanut
and grape foods
of uncooked butter or
tomatoes Ice cubes
dried other nut
vegetables and seed
butters
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
844 | Infancy
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
Infancy | 845
2526
associated with decreased risk of developing food allergies. A
landmark study done in 2015 showed that infants with 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
27
age. 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
25. Alvisi P, Brusa S, Alboresi S. (2015). Recommendations on

complementary feeding for healthy, full-term infants.
Italian Journal of Pediatrics,
41(36) https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC4464122/
26. Gever J. (2012, March 7). Nursing mom’s diet no guard
against baby allergies. Medpage Today.
http://www.medpagetoday.com/MeetingCoverage/
AAAAIMeeting/31527
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.
846 | Infancy
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.
Infancy | 847
Newborn Jaundice
Image by
Centers for
Disease
Control and
Prevention /
Public
Domain
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. Bilirubin is a substance created
848 | Infancy
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.
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
Infancy | 849
a few weeks, as the baby begins to mature and red blood cell levels
28
diminish, jaundice typically subsides with no lingering effects.
Learning Activities

Open Document).


28. American Pregnancy Association. Breastfeeding and

jaundice. http://www.americanpregnancy.org/
firstyearoflife/breastfeedingandjaundice.htm
850 | Infancy
Infancy | 851
Toddler Years
Image by
kazuend on
unsplash.co
m / CC0
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
1
ossification is not completed until puberty. Journey across the life
span: Human development and health promotion. F.A. Davis Co.
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
1. Polan, E., & Taylor, D. (2003).
852 | Toddler Years

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.
MyPlate may be used as a guide for the toddler’s diet

(http://www.choosemyplate.gov/preschoolers.html). 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
Toddler Years | 853

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 13.6 “Serving Sizes for Toddlers” for some examples.
Table 13.6 Serving Sizes for Toddlers
Food Group Daily Serving Examples
• 3 slices of br
About 3-5 ounces of grains per day, ideally whole
Grains • 1 slice of brea
grains
rice or pasta
• 1 ounce of lea
Proteins 2-4 ounces of meat, poultry, fish, eggs, or legumes
• 1 ounce of fis
• 1 small apple
1-1.5 cups of fresh, frozen, canned, and/or dried
Fruits • 1 cup of slice
fruits, or 100 percent fruit juice
• 1 large banan
• 1 cup of pure
Vegetables 1-1.5 cups of raw and/or cooked vegetables
potato, chop
• 2 cups of fat-
Dairy
2-2.5 cups per day • 1 cup of fat-f
Products
• 1 cup of fat-f
854 | Toddler Years

Source: Hayes, D. (2018, February 20). It‘s about eating right: Size-
wise nutrition for toddlers. Academy of Nutrition and Dietetics.
https://www.eatright.org/food/nutrition/dietary-guidelines-
and-myplate/what-and-how-much-should-my-preschooler-be-
eating
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
Toddler Years | 855

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:
• 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,
856 | Toddler Years

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
2
• avoiding letting children eat in between meal- or snack-times
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
2. Satter, E. (2016). Ellyn Satter’s division of responsibility in

feeding. https://www.ellynsatterinstitute.org/wp-
content/uploads/2016/11/handout-dor-tasks-
cap-2016.pdf
Toddler Years | 857

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: https://health.hawaii.gov/wic/
files/2019/03/Cookbook-Keiki-Can-Cook.pdf.
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
3
than doubled for all children, including infants and toddlers.
Almost 10 percent of infants and toddlers weigh more than they
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. https://www.cdc.gov/nchs/
data/hestat/obesity_child_07_08/
obesity_child_07_08.htm
858 | Toddler Years

should considering their length, and slightly more than 20 percent
4
of children ages two to five are overweight or have obesity.
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
567
10.2% had obesity. 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
8
study population was overweight and 14% had obesity.
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.
6. Thorn B., Tadler C., Huret N., Ayo E., Trippe C. (2015,
November). WIC participant and program characteristics
final report. https://fns-prod.azureedge.net/sites/
default/files/ops/WICPC2014.pdf
7. State of childhood obesity. Obesity rates & trend data.
https://stateofchildhoodobesity.org/data/
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.
http://chl-pacific.org/wp-content/uploads/2011/08/
Novotny-et-
Toddler Years | 859

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, 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
al-2016-Prevalence_of_obesity_and_acanthosis_nigric
ans.-Medicine.pdf
860 | Toddler Years

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
9
of added sugar per day. 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.
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.
Toddler Years | 861

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
10
help to improve iron absorption.
Learning Activities

10. Louis A., Kazal J.R. (2002). Prevention of Iron deficiency

in infants and toddlers. American Academy of Family
Physicians, 66(7), 1217—25. http://www.aafp.org/afp/
2002/1001/p1217.html.
862 | Toddler Years

Open Document).



Toddler Years | 863

PART XIV
NUTRITION DURING
CHILDHOOD AND
ADOLESCENCE
Chapter 14. Lifespan Nutrition During

Childhood and Adolescence | 865
Introduction
E mālama ‘ia nā pono o ka ‘āina e na ‘ōpio
The traditions of the land are perpetuated by its youth
Image by
Brytni
K-aloha /
CC BY 4.0
Introduction | 867
Learning Objectives

requirements during childhood and adolescence.
Early childhood encompasses infancy and the toddler years, from

birth through age three. The remaining part of childhood is the
period from ages four through eight and is the time when children
enter school. A number of critical physiological and emotional
changes take place during the life stage from childhood through
adolescences. Children’s attitudes and opinions about food deepen.
They not only begin taking their cues about food preferences from
family members, but also from peers and the larger culture. In
Hawai‘i, organizations such as the Kōkua Hawai‘i Foundation have
implemented school programs such as ‘Āina In Schools to connect
children to their local land, waters, and food. The program initiative
is to address childhood health issues by fostering healthy eating
habits by teaching and engaging youth about local and traditional
1
foods.
Parents also greatly impact their child’s nutritional choices. This
time in a child’s life provides an opportunity for parents and other
caregivers to reinforce good eating habits and to introduce new
foods into the diet, while remaining mindful of a child’s preferences.
Parents should also serve as role models for their children, who will
1. About ‘Āina In Schools. Kōkua Hawai‘i Foundation.

https://www.kokuahawaiifoundation.org/aina. Accessed
February 16, 2018.
868 | Introduction
often mimic their behavior and eating habits. Parents must continue
to help their school-aged children and adolescents establish healthy
eating habits and attitudes toward food. Their primary role is to
bring a wide variety of health-promoting foods into the home, so
that their children can make good choices.
Learning Activities

Open Document).


Introduction | 869
870 | Introduction
Childhood
Image by
Brytni
K-aloha /
CC BY 4.0
Nutritional needs change as children leave the toddler years. From

ages four to eight, school-aged children grow consistently, but at
a slower rate than infants and toddlers. They also experience the
loss of deciduous, or “baby,” teeth and the arrival of permanent
teeth, which typically begins at age six or seven. As new teeth come
Childhood | 871
in, many children have some malocclusion, or malposition, of their
teeth, which can affect their ability to chew food. Other changes
that affect nutrition include the influence of peers on dietary
choices and the kinds of foods offered by schools and afterschool
programs, which can make up a sizable part of a child’s diet. Food-
related problems for young children can include tooth decay, food
sensitivities, and malnourishment. Also, excessive weight gain early
in life can lead to obesity into adolescence and adulthood.
At this life stage, a healthy diet facilitates physical and mental
development and helps to maintain health and wellness. School-
aged children experience steady, consistent growth, with an average
growth rate of 2–3 inches (5–7 centimeters) in height and 4.5–6.5
pounds (2–3 kilograms) in weight per year. In addition, the rate
of growth for the extremities is faster than for the trunk, which
results in more adult-like proportions. Long-bone growth stretches
muscles and ligaments, which results in many children experiencing
1
“growing pains,” at night, in particular.
Energy
Children’s energy needs vary, depending on their growth and level

of physical activity. Energy requirements also vary according to
gender. Girls ages four to eight require 1,200 to 1,800 calories a
day, while boys need 1,200 to 2,000 calories daily, and, depending
on their activity level, maybe more. Also, recommended intakes of
macronutrients and most micronutrients are higher relative to body
size, compared with nutrient needs during adulthood. Therefore,
1. Polan EU, Taylor DR. (2003). Journey Across the LifeSpan:

Human Development and Health Promotion. Philadelphia:
F. A. Davis Company, 150–51.
872 | Childhood
children should be provided nutrient-dense food at meal- and
snack-time. However, it is important not to overfeed children, as
this can lead to childhood obesity, which is discussed in the next
section. Parents and other caregivers can turn to the MyPlate
website for guidance: http://www.choosemyplate.gov/.
Macronutrients
For carbohydrates, the Acceptable Macronutrient Distribution

Range (AMDR) is 45–65 percent of daily calories (which is a
recommended daily allowance of 135–195 grams for 1,200 daily
calories). Carbohydrates high in fiber should make up the bulk of
intake. The AMDR for protein is 10–30 percent of daily calories
(30–90 grams for 1,200 daily calories). Children have a high need for
protein to support muscle growth and development. High levels of
essential fatty acids are needed to support growth (although not as
high as in infancy and the toddler years). As a result, the AMDR for
fat is 25–35 percent of daily calories (33–47 grams for 1,200 daily
calories). Children should get 17–25 grams of fiber per day.
Micronutrients
Micronutrient needs should be met with foods first. Parents and

caregivers should select a variety of foods from each food group
to ensure that nutritional requirements are met. Because children
grow rapidly, they require foods that are high in iron, such as lean
meats, legumes, fish, poultry, and iron-enriched cereals. Adequate
fluoride is crucial to support strong teeth. One of the most
important micronutrient requirements during childhood is
adequate calcium and vitamin D intake. Both are needed to build
dense bones and a strong skeleton. Children who do not consume
Childhood | 873
adequate vitamin D should be given a supplement of 10 micrograms
(400 international units) per day. Table 14.1 “Micronutrient Levels
during Childhood” shows the micronutrient recommendations for
school-aged children. (Note that the recommendations are the
same for boys and girls. As we progress through the different stages
of the human life cycle, there will be some differences between
males and females regarding micronutrient needs.)
Table 14.1 Micronutrient Levels during Childhood
874 | Childhood
Nutrient Children, Ages 4–8
Vitamin A (mcg) 400.0
Vitamin B6 (mcg) 600.0
Vitamin C (mg) 25.0
Vitamin D (mcg) 5.0
Vitamin E (mg) 7.0
Vitamin K (mcg) 55.0
Calcium (mg) 800.0
Folate (mcg) 200.0
Iron (mg) 10.0
Childhood | 875
Magnesium (mg) 130.0
Niacin(B3) (mg) 8.0
Phosphorus (mg) 500.0
Riboflavin (B2) (mcg) 600.0
Selenium (mcg) 30.0
Thiamine (B1) (mcg) 600.0
Zinc (mg) 5.0
Source:Institute of Medicine. 2006. Dietary Reference Intakes: The

Essential Guide to Nutrient Requirements. Washington, DC: The
National Academies Press. https://doi.org/10.17226/11537. Accessed
December 10, 2017.
Factors Influencing Intake
A number of factors can influence children’s eating habits and

attitudes toward food. Family environment, societal trends, taste
preferences, and messages in the media all impact the emotions
that children develop in relation to their diet. Television
commercials can entice children to consume sugary products, fatty
fast-foods, excess calories, refined ingredients, and sodium.
876 | Childhood
Therefore, it is critical that parents and caregivers direct children
toward healthy choices.
One way to encourage children to eat healthy foods is to make
meal- and snack-time fun and interesting. Parents should include
children in food planning and preparation, for example selecting
items while grocery shopping or helping to prepare part of a meal,
such as making a salad. At this time, parents can also educate
children about kitchen safety. It might be helpful to cut sandwiches,
meats, or pancakes into small or interesting shapes. In addition,
parents should offer nutritious desserts, such as fresh fruits, instead
of calorie-laden cookies, cakes, salty snacks, and ice cream. Also,
studies show that children who eat family meals on a frequent basis
2
consume more nutritious foods.
Children and Malnutrition
Malnutrition is a problem many children face, in both developing

nations and the developed world. Even with the wealth of food
in North America, many children grow up malnourished, or even
hungry. The US Census Bureau characterizes households into the
following groups:
• food secure
• food insecure without hunger
• food insecure with moderate hunger
2. Research on the Benefits of Family Meals. Dakota

County, Minnesota. https://www.co.dakota.mn.us/
HealthFamily/HealthyLiving/DietNutrition/
Documents/ReturnFamilyMeals.doc. Updated April 30,
2012. Accessed December 4, 2017.
Childhood | 877
• food insecure with severe hunger
Millions of children grow up in food-insecure households with

inadequate diets due to both the amount of available food and the
quality of food. In the United States, about 20 percent of households
with children are food insecure to some degree. In half of those,
only adults experience food insecurity, while in the other half both
adults and children are considered to be food insecure, which
means that children did not have access to adequate, nutritious
3
meals at times.
Growing up in a food-insecure household can lead to a number
of problems. Deficiencies in iron, zinc, protein, and vitamin A can
result in stunted growth, illness, and limited development. Federal
programs, such as the National School Lunch Program, the School
Breakfast Program, and Summer Feeding Programs, work to address
the risk of hunger and malnutrition in school-aged children. They
help to fill the gaps and provide children living in food-insecure
households with greater access to nutritious meals.
The National School Lunch Program
Beginning with preschool, children consume at least one of their

meals in a school setting. Many children receive both breakfast and
lunch outside of the home. Therefore, it is important for schools
to provide meals that are nutritionally sound. In the United States,
more than thirty-one million children from low-income families
are given meals provided by the National School Lunch Program.
This federally-funded program offers low-cost or free lunches to
3. Coleman-Jensen A, et al. (2011). Household Food Security

in the United States in 2010. US Department of
Agriculture, Economic Research Report, no. ERR-125.
878 | Childhood
schools, and also snacks to after-school facilities. School districts
that take part receive subsidies from the US Department of
Agriculture (USDA) for every meal they serve. School lunches must
meet the 2015 Dietary Guidelines for Americans and need to provide
one-third of the RDAs for protein, vitamin A, vitamin C, iron, and
calcium. However, local authorities make the decisions about what
4
foods to serve and how they are prepared.
The Healthy School Lunch Campaign works to improve the food
served to children in school and to promote children’s short- and
long-term health by educating government officials, school officials,
food-service workers, and parents. Sponsored by the Physicians
Committee for Responsible Medicine, this organization encourages
schools to offer more low-fat, cholesterol-free options in school
5
cafeterias and in vending machines.
Food Allergies and Food Intolerance
As discussed previously, the development of food allergies is a

concern during the toddler years. This remains an issue for school-
4. ENational School Lunch Program Fact Sheet. US

Department of Agriculture. https://fns-
prod.azureedge.net/sites/default/files/cn/
NSLPFactSheet.pdf. Published 2011. Accessed December
4, 2017.nter your footnote content here.
5. Healthy School Lunches. Physicians Committee for
Responsible Medicine.
http://healthyschoollunches.org/. Accessed March 5,
2012.
Childhood | 879
aged children. Recent studies show that three million children
6
under age eighteen are allergic to at least one type of food.
Some of the most common allergenic foods include peanuts, milk,
eggs, soy, wheat, and shellfish. An allergy occurs when a protein
in food triggers an immune response, which results in the release
of antibodies, histamine, and other defenders that attack foreign
bodies. Possible symptoms include itchy skin, hives, abdominal pain,
vomiting, diarrhea, and nausea. Symptoms usually develop within
minutes to hours after consuming a food allergen. Children can
outgrow a food allergy, especially allergies to wheat, milk, eggs, or
soy.
Anaphylaxis is a life-threatening reaction that results in difficulty
breathing, swelling in the mouth and throat, decreased blood
pressure, shock, or even death. Milk, eggs, wheat, soybeans, fish,
shellfish, peanuts, and tree nuts are the most likely to trigger this
type of response. A dose of the drug epinephrine is often
administered via a “pen” to treat a person who goes into
7
anaphylactic shock.
Some children experience a food intolerance, which does not
involve an immune response. A food intolerance is marked by
unpleasant symptoms that occur after consuming certain foods.
Lactose intolerance, though rare in very young children, is one
6. Allergy Statistics. American Academy of Allergy, Asthma

and Immunology. http://www.aaaai.org/about-the-
aaaai/newsroom/allergy-statistics.aspx. Accessed on
March 5, 2012.
7. Food Allergy Quick Facts. National Institutes of Health,
US Department of Health and Human Services.
http://www.niaid.nih.gov/topics/foodallergy/
understanding/pages/quickfacts.aspx. Updated March
27, 2017. Accessed December 10, 2017.
880 | Childhood
example. Children who suffer from this condition experience an
adverse reaction to the lactose in milk products. It is a result of
the small intestine’s inability to produce enough of the enzyme
lactase, which is produced by the small intestine. Symptoms of
lactose intolerance usually affect the GI tract and can include
bloating, abdominal pain, gas, nausea, and diarrhea. An intolerance
is best managed by making dietary changes and avoiding any foods
8
that trigger the reaction.
The Threat of Lead Toxicity
There is a danger of lead toxicity, or lead poisoning, among school-

aged children. Lead is found in plumbing in old homes, in lead-based
paint, and occasionally in the soil. Contaminated food and water can
increase exposure and result in hazardous lead levels in the blood.
Children under age six are especially vulnerable. They may consume
items tainted with lead, such as chipped, lead-based paint. Another
common exposure is lead dust in carpets, with the dust flaking off
of paint on walls. When children play or roll around on carpets
coated with lead, they are in jeopardy. Lead is indestructible, and
once it has been ingested it is difficult for the human body to alter
or remove it. It can quietly build up in the body for months, or even
years, before the onset of symptoms. Lead toxicity can damage the
brain and central nervous system, resulting in impaired thinking,
reasoning, and perception.
8. Lactose Intolerance. National Institute of Diabetes and

Digestive and Kidney Diseases.
http://digestive.niddk.nih.gov/ddiseases/pubs/
lactoseintolerance/. Updated June 2014. Accessed
December 4, 2017.
Childhood | 881
Treatment for lead poisoning includes removing the child from
the source of contamination and extracting lead from the body.
Extraction may involve chelation therapy, which binds with lead
so it can be excreted in urine. Another treatment protocol, EDTA
therapy, involves administering a drug called
ethylenediaminetetraacetic acid to remove lead from the
9
bloodstream of patients with levels greater than 45 mcg/dL.
Fortunately, lead toxicity is highly preventable. It involves
identifying potential hazards, such as lead paint and pipes, and
removing them before children are exposed to them.
Learning Activities

Open Document).

9. Lead Exposure: Tips to Protect Your Child. Mayo

Foundation for Medical Education and Research.
https://www.mayoclinic.org/diseases-conditions/lead-
poisoning/in-depth/lead-exposure/art-20044627.
Updated March 12, 2015. Accessed December 5, 2017.
882 | Childhood

Childhood | 883
Adolescence
Image by
Peter
Hershey on
unsplash.co
m / CC0
The onset of puberty is the beginning of adolescence and is the

bridge between the childhood years and young adulthood.
According to the DRI recommendations, adolescence is divided into
two age groups: 9 through 13 years, and 14 through 18 years. Some
of the important physiological changes that take place during this
stage include the development of primary sex characteristics, or
the reproductive organs, along with the onset of menstruation in
females. This life stage is also characterized by the appearance of
secondary sex characteristics, such as the growth of facial and body
hair, the development of breasts in girls, and the deepening of the
voice in boys. Other physical changes include rapid growth and
1
alterations in body proportions. All of these changes, as well as
884 | Adolescence
the accompanying mental and emotional adjustments, should be
supported with sound nutrition.
The Onset of Puberty (Ages 9 through 13 years)
This period of physical development is divided into two phases.

The first phase involves height increases from 20 to 25 percent.
Puberty is second to the prenatal period in terms of rapid growth
as the long bones stretch to their final, adult size. Girls grow 2–8
inches (5–20 centimeters) taller, while boys grow 4–12 inches (10–30
centimeters) taller. The second phase involves weight gain related to
the development of bone, muscle, and fat tissue. Also in the midst of
puberty, the sex hormones trigger the development of reproductive
organs and secondary sexual characteristics, such as pubic hair.
Girls also develop “curves,” while boys become broader and more
2
muscular.
The energy requirements for preteens differ according to gender,

growth, and activity level. For ages nine to thirteen, girls should
consume about 1,400 to 2,200 calories per day and boys should
consume 1,600 to 2,600 calories per day. Physically active preteens

F. A. Davis Company; 170–71.
2. McMillan B. (2008). Illustrated Atlas of the Human Body.
Sydney, Australia: Weldon Owen, 258.
Adolescence | 885
who regularly participate in sports or exercise need to eat a greater
number of calories to account for increased energy expenditures.
For carbohydrates, the AMDR is 45 to 65 percent of daily calories
(which is a recommended daily allowance of 158–228 grams for
1,400–1,600 daily calories). Carbohydrates that are high in fiber
should make up the bulk of intake. The AMDR for protein is 10 to 30
percent of daily calories (35–105 grams for 1,400 daily calories for
girls and 40–120 grams for 1,600 daily calories for boys). The AMDR
for fat is 25 to 35 percent of daily calories (39–54 grams for 1,400
daily calories for girls and 44–62 grams for 1,600 daily calories for
boys), depending on caloric intake and activity level.
Micronutrients
Key vitamins needed during puberty include vitamins D, K, and

B12. Adequate calcium intake is essential for building bone and
preventing osteoporosis later in life. Young females need more iron
at the onset of menstruation, while young males need additional
iron for the development of lean body mass. Almost all of these
needs should be met with dietary choices, not supplements (iron
is an exception). Table 14.2 “Micronutrient Levels during Puberty”
shows the micronutrient recommendations for young adolescents.
Table 14.2 Micronutrient Levels during Puberty
886 | Adolescence
Preteens, Ages
Nutrient
9–13
Vitamin A (mcg) 600.0
Vitamin B6 (mg) 1.0
Vitamin C (mg) 45.0
Vitamin D (mcg) 5.0
Vitamin E (mg) 11.0
Vitamin K (mcg) 60.0

Calcium (mg) 1,300.0
Folate (mcg) 300.0
Iron (mg) 8.0
Magnesium (mg) 240.0
Niacin (B3) (mg) 12.0

Phosphorus (mg) 1,250.0
Riboflavin (B2) (mcg) 900.0
Selenium (mcg) 40.0
Thiamine (B1) (mcg) 900.0
Zinc (mg) 8.0
Source: Institute of Medicine. 2006. Dietary Reference Intakes: The

December 10, 2017.
Adolescence | 887
Learning Activities

Open Document).


888 | Adolescence
Late Adolescence
Image by
Riley
McCullough
on
unsplash.co
m / CC0
After puberty, the rate of physical growth slows down. Girls stop
growing taller around age sixteen, while boys continue to grow
taller until ages eighteen to twenty. One of the psychological and
emotional changes that takes place during this life stage includes
the desire for independence as adolescents develop individual
1
identities apart from their families. As teenagers make more and
more of their dietary decisions, parents or other caregivers and
authority figures should guide them toward appropriate, nutritious
choices. One way that teenagers assert their independence is by
choosing what to eat. They have their own money to purchase food

Late Adolescence | 889

and tend to eat more meals away from home. Older adolescents
also can be curious and open to new ideas, which includes trying
new kinds of food and experimenting with their diet. For example,
teens will sometimes skip a main meal and snack instead. That is
not necessarily problematic. Their choice of food is more important
than the time or place.
However, too many poor choices can make young people
nutritionally vulnerable. Teens should be discouraged from eating
fast food, which has a high fat and sugar content, or frequenting
convenience stores and using vending machines, which typically
offer poor nutritional selections. Other challenges that teens may
face include obesity and eating disorders. At this life stage, young
people still need guidance from parents and other caregivers about
nutrition-related matters. It can be helpful to explain to young
people how healthy eating habits can support activities they enjoy,
such as skateboarding or dancing, or connect to their desires or
interests, such as a lean figure, athletic performance, or improved
cognition.
As during puberty, growth and development during adolescence
differs in males than in females. In teenage girls, fat assumes a larger
percentage of body weight, while teenage boys experience greater
muscle and bone increases. For both, primary and secondary sex
characteristics have fully developed and the rate of growth slows
with the end of puberty. Also, the motor functions of an older
2
adolescent are comparable to those of an adult. Again, adequate
nutrition and healthy choices support this stage of growth and
development.
2. Polan EU, Taylor DR. (2003). Journey Across the Life Span:
890 | Late Adolescence

Adolescents have increased appetites due to increased nutritional

requirements. Nutrient needs are greater in adolescence than at any
other time in the life cycle, except during pregnancy. The energy
requirements for ages fourteen to eighteen are 1,800 to 2,400
calories for girls and 2,000 to 3,200 calories for boys, depending on
activity level. The extra energy required for physical development
during the teenaged years should be obtained from foods that
provide nutrients instead of “empty calories.” Also, teens who
participate in sports must make sure to meet their increased energy
needs.
Older adolescents are more responsible for their dietary choices
than younger children, but parents and caregivers must make sure
that teens continue to meet their nutrient needs. For
carbohydrates, the AMDR is 45 to 65 percent of daily calories
(203–293 grams for 1,800 daily calories). Adolescents require more
servings of grain than younger children, and should eat whole
grains, such as wheat, oats, barley, and brown rice. The Institute of
Medicine recommends higher intakes of protein for growth in the
adolescent population. The AMDR for protein is 10 to 30 percent
of daily calories (45–135 grams for 1,800 daily calories), and lean
proteins, such as meat, poultry, fish, beans, nuts, and seeds are
excellent ways to meet those nutritional needs.
The AMDR for fat is 25 to 35 percent of daily calories (50–70 grams
for 1,800 daily calories), and the AMDR for fiber is 25–34 grams per
day, depending on daily calories and activity level. It is essential for
young athletes and other physically active teens to intake enough
fluids, because they are at a higher risk for becoming dehydrated.

Micronutrients
Micronutrient recommendations for adolescents are mostly the

same as for adults, though children this age need more of certain
minerals to promote bone growth (e.g., calcium and phosphorus,
along with iron and zinc for girls). Again, vitamins and minerals
should be obtained from food first, with supplementation for
certain micronutrients only (such as iron).
The most important micronutrients for adolescents are calcium,
vitamin D, vitamin A, and iron. Adequate calcium and vitamin D are
essential for building bone mass. The recommendation for calcium
is 1,300 milligrams for both boys and girls. Low-fat milk and cheeses
are excellent sources of calcium and help young people avoid
saturated fat and cholesterol. It can also be helpful for adolescents
to consume products fortified with calcium, such as breakfast
cereals and orange juice. Iron supports the growth of muscle and
lean body mass. Adolescent girls also need to ensure sufficient iron
intake as they start to menstruate. Girls ages twelve to eighteen
require 15 milligrams of iron per day. Increased amounts of vitamin
C from orange juice and other sources can aid in iron absorption.
Also, adequate fruit and vegetable intake allows for meeting vitamin
A needs. Table 14.3 “Micronutrient Levels during Older Adolescence”
shows the micronutrient recommendations for older adolescents,
which differ slightly for males and females, unlike the
recommendations for puberty.
Table 14.3 Micronutrient Levels during Older Adolescence

Nutrient Males, Ages 14–18 Females, Ages 14–18

Vitamin C (mg) 75.0 65.0

Vitamin D (mcg) 5.0 5.0
Vitamin E (mg) 15.0 15.0
Vitamin K (mcg) 75.0 75.0
Calcium (mg) 1,300.0 1,300.0
Folate mcg) 400.0 400.0

Iron (mg) 11.0 15.0
Magnesium (mg) 410.0 360.0
Niacin (B3) (mg) 16.0 14.0
Phosphorus (mg) 1,250.0 1,250.0
Riboflavin (B2) (mg) 1.3 1.0

Selenium (mcg) 55.0 55.0
Thiamine (B1) (mg) 1.2 1.0
Zinc (mg) 11.0 9.0

December 10, 2017.
Eating Disorders
Many teens struggle with an eating disorder, which can have a

detrimental effect on diet and health. A study published by North
Dakota State University estimates that these conditions impact
twenty-four million people in the United States and seventy million

3
worldwide. These disorders are more prevalent among adolescent
girls, but have been increasing among adolescent boys in recent
years. Because eating disorders often lead to malnourishment,
adolescents with an eating disorder are deprived of the crucial
nutrients their still-growing bodies need.
Eating disorders involve extreme behavior related to food and
exercise. Sometimes referred to as “starving or stuffing,” they
encompass a group of conditions marked by under eating or
overeating. Some of these conditions include:
• Anorexia Nervosa. Anorexia nervosa is a potentially fatal

condition characterized by under eating and excessive weight
loss. People with this disorder are preoccupied with dieting,
calories, and food intake to an unhealthy degree. Anorexics
have a poor body image, which leads to anxiety, avoidance of
food, a rigid exercise regimen, fasting, and a denial of hunger.
The condition predominantly affects females. Between 0.5 and
1 percent of American women and girls suffer from this eating
disorder.
• Binge-Eating Disorder. People who suffer from binge-eating
disorder experience regular episodes of eating an extremely
large amount of food in a short period of time. Binge eating is a
compulsive behavior, and people who suffer from it typically
feel it is beyond their control. This behavior often causes
feelings of shame and embarrassment, and leads to obesity,
high blood pressure, high cholesterol levels, Type 2 diabetes,
and other health problems. Both males and females suffer from
binge-eating disorder. It affects 1 to 5 percent of the
3. Eating Disorder Statistics. North Dakota State

University. http://www.ndsu.edu/fileadmin/
counseling/Eating_Disorder_Statistics.pdf. Accessed
March 5, 2012.

population.
• Bulimia Nervosa. Bulimia nervosa is characterized by
alternating cycles of overeating and undereating. People who
suffer from it partake in binge eating, followed by
compensatory behavior, such as self-induced vomiting, laxative
use, and compulsive exercise. As with anorexia, most people
with this condition are female. Approximately 1 to 2 percent of
4
American women and girls have this eating disorder.
Eating disorders stem from stress, low self-esteem, and other

psychological and emotional issues. It is important for parents to
watch for signs and symptoms of these disorders, including sudden
weight loss, lethargy, vomiting after meals, and the use of appetite
suppressants. Eating disorders can lead to serious complications
or even be fatal if left untreated. Treatment includes cognitive,
behavioral, and nutritional therapy.
Childhood and Adolescent Obesity
Children need adequate caloric intake for growth, and it is

important not to impose very restrictive diets. However, exceeding
caloric requirements on a regular basis can lead to childhood
obesity, which has become a major problem in North America.
Nearly one of three US children and adolescents are overweight or
5
obese.
4. Learn By Eating Disorder. National Eating Disorders

Association.https://www.nationaleatingdisorders.org/
learn/by-eating-disorder . Accessed December 4, 2017.
5. Learn the Facts. Let’s Move.
https://letsmove.obamawhitehouse.archives.gov/learn-

There are a number of reasons behind this problem, including:
• larger portion sizes

• limited access to nutrient-rich foods
• increased access to fast foods and vending machines
• lack of breastfeeding support
• declining physical education programs in schools
• insufficient physical activity and a sedentary lifestyle
• media messages encouraging the consumption of unhealthy
foods
Children who suffer from obesity are more likely to become

overweight or obese adults. Obesity has a profound effect on self-
esteem, energy, and activity level. Even more importantly, it is a
major risk factor for a number of diseases later in life, including
cardiovascular disease, Type 2 diabetes, stroke, hypertension, and
6
certain cancers.
A percentile for body mass index (BMI) specific to age and sex is
used to determine if a child is overweight or obese. This is more
appropriate than the BMI categories used for adults because the
body composition of children varies as they develop, and differs
between boys and girls. If a child gains weight inappropriate to
growth, parents and caregivers should limit energy-dense,
nutrient-poor snack foods. In addition, it is extremely beneficial
to increase a child’s physical activity and limit sedentary activities,
facts/epidemic-childhood-obesity. Accessed December

5, 2017.
6. Obesity and Overweight Fact Sheet. World Health
Organization. http://www.who.int/mediacentre/
factsheets/fs311/en/. Updated October 2017. Accessed
November 29, 2017.

such as watching television, playing video games, or surfing the
Internet.
Programs to address childhood obesity can include behavior
modification, exercise counseling, psychological support or
therapy, family counseling, and family meal-planning advice. For
most, the goal is not weight loss, but rather allowing height to catch
up with weight as the child continues to grow. Rapid weight loss is
not recommended for preteens or younger children due to the risk
of deficiencies and stunted growth.
Avoiding Added Sugars
One major contributing factor to childhood obesity is the

consumption of added sugars. Added sugars include not only sugar
added to food at the table, but also are ingredients in items such as
bread, cookies, cakes, pies, jams, and soft drinks. The added sugar
in store-bought items may be listed as white sugar, brown sugar,
high-fructose corn syrup, honey, malt syrup, maple syrup, molasses,
anhydrous dextrose, crystal dextrose, and concentrated fruit juice.
(Not included are sugars that occur naturally in foods, such as the
lactose in milk or the fructose in fruits.) In addition, sugars are
often “hidden” in items added to foods after they’re prepared, such
as ketchup, salad dressing, and other condiments. According to
the National Center for Health Statistics, young children and
adolescents consume an average of 322 calories per day from added
7
sugars, or about 16 percent of daily calories.
7. Ervin RB, Kit BK, Carroll MD. (2012). Consumption of

Added Sugar among US Children and Adolescents,
2005–2008. National Center for Health Statistics. NCHS

The primary offenders are processed and packaged foods, along
with soda and other beverages. These foods are not only high in
sugar, they are also light in terms of nutrients and often take the
place of healthier options. Intake of added sugar should be limited
to 100–150 calories per day to discourage poor eating habits.
Tools for Change
The 2008 Physical Activity Guidelines for Americans call for sixty
minutes of moderate to vigorous physical activity daily for preteens
and teens. This includes aerobic activity, along with bone- and
8
muscle-strengthening exercises. However, many young people fall
far short of this goal. Preteens must be encouraged to lead more
active lifestyles to prevent or treat childhood obesity. In the United
States, the Let’s Move! campaign inspires kids to start exercising.
This program, launched in 2010 by First Lady Michelle Obama,
works to solve the problem of rising obesity rates among children,
preteens, and teens. It offers information to parents and educators,
works to provide healthier food choices in schools and afterschool
programs, and helps children become more active. One way the
program promotes physical activity is by encouraging preteens and
teens to find something they love to do. When kids find an activity
they enjoy, whether riding a bike, playing football, joining a soccer
team, or participating in a dance crew, they are more likely to get
Data Brief, 87. http://www.cdc.gov/nchs/data/

databriefs/db87.pdf. Accessed December 5, 2017.
http://www.health.gov/paguidelines/pdf/paguide.pdf.
Accessed March 5, 2012.

moving and stay healthy. You can learn more about Let’s Move!
and efforts to encourage physical activity among adolescents at this
website: http://www.letsmove.gov/.
Learning Activities

Open Document).




PART XV
NUTRITION IN
ADULTHOOD
Chapter 15. Lifespan Nutrition in

Adulthood | 901
Introduction
E ola koa.
Live like a koa tree.
Image by
nic.co on
unsplash.co
m / CCO
Learning Objectives
Introduction | 903
requirements during adulthood.
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
1
activity helps to improve muscle strength, endurance, and tone.
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
2
meet the recommended guidelines for both. To learn more about
the current physical activity guidelines visit https://www.cdc.gov/
cancer/dcpc/prevention/policies_practices/physical_activity/
guidelines.htm.
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

2. Hawaii Physical Activity and Nutrition Plan, 2013-2020.
https://health.hawaii.gov/physical-activity-nutrition/
files/2013/08/Hawaii-PAN-Plan-2013-2020.pdf.
Accessed February 16, 2018.
904 | Introduction
Dietary Guidelines recommend eating a balanced diet from the five
3
food groups: fruits, vegetables, protein, grains and dairy. 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
4
lead to several health issues. Consuming diets high in fruits and
vegetables may have health benefits such as a reduced risk for heart
5
disease, and protection against certain cancers.
Learning Activities

3. All About the Fruit Group. USDA ChooseMyPlate.gov.

https://www.choosemyplate.gov/fruit Accessed
February 16, 2018.
4. Hawai‘i Physical Activity and Nutrition Plan, 2013-2020.
https://health.hawaii.gov/physical-activity-nutrition/
files/2013/08/Hawaii-PAN-Plan-2013-2020.pdf.
Accessed February 16, 2018.
5. Nutrients and Health Benefits. USDA
ChooseMyPlate.gov. https://www.choosemyplate.gov/
fruits-nutrients-health. Accessed February 16, 2018.
Introduction | 905
Open Document).


906 | Introduction
Young Adulthood
Image by
David Marcu
on
unsplash.co
m / CC0
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
1
forty. 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
Young Adulthood | 907

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.
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.
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
908 | Young Adulthood

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.
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
15.1 “Micronutrient Levels during Adulthood” shows the
micronutrient recommendations for adult men and women.
Table 15.1 Micronutrient Levels during Adulthood

Nutrient Adult Males Adult Females

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

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

2
is 2.7 liters per day, from food and liquids. 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 considered
3
to be obese. 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
2. Institute of Medicine. 2005. Dietary Reference Intakes

for Water, Potassium, Sodium, Chloride, and Sulfate.
https://doi.org/10.17226/10925. Accessed December 10,
2017.
3. Prevalence of Obesity in the United States, 2009–2010.
Centers for Disease Control, National Center for Health
Statistics.NCHS Data Brief, No. 82. http://www.cdc.gov/
nchs/data/databriefs/db82.pdf. Published January 2012.

levels of saturated fat and cholesterol and insufficient dietary fiber.
Therefore, it is important to limit unrefined carbohydrates and
processed foods.
Learning Activities

Open Document).



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
1
at a close distance, a condition known as presbyopia. 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
2
the connective tissue. Many people in their late thirties and in
2. Polan EU, Taylor DR. (2003), Journey Across the Life Span:
Middle Age | 913

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
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
3
tomatoes—account for over half of all vegetable intake. Following
3. Drewnowski A, Darmon, N. (2005). Food Choices and

Diet Cost: an Economic Analysis. The Journal of
Nutrition, 135(4), 900-904. http://jn.nutrition.org/
content/135/4/900.full. Accessed December 12, 2017.
914 | Middle Age

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
Middle Age | 915

example is consuming foods high in antioxidants, such as
strawberries, blueberries, and other colorful fruits and vegetables,
to reduce the risk of cancer.
Phytochemicals are also great nonessential nutrients that may

promote body wellness.For 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
4
ongoing. 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
5
cancer, although more research is needed.
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.
4. Voutilainen S, Nurmi T, Mursu J, Rissanen, TH. (2006).

Carotenoids and Cardiovascular Health.
American Journals of Clinical Nutrition, 83, 1265–71.
http://www.ajcn.org/content/83/6/1265.full.pdf.
5. Lycopene. American Cancer Society.
http://www.cancer.org/Treatment/
TreatmentsandSideEffects/
ComplementaryandAlternativeMedicine/
DietandNutrition/lycopene. Updated May 13, 2010.
916 | Middle Age

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
6
complete everyday tasks, such as cooking, bathing, and dressing.
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
6. Eating Right During Menopause.Academy of Nutrition

and Dietetics. http://www.eatright.org/Public/
content.aspx?id=6809. Updated January 2015. Accessed
December 4, 2017.
Middle Age | 917

and reduce the risk of falls and fractures
Learning Activities

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918 | Middle Age

Older Adulthood: The
Golden Years
“Man
wearing blue
shirt
standing on
white
surfboard”
by Alex
Blajan /
Unsplash
License
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
1
when estrogen and testosterone levels begin to decline. Also in

Older Adulthood: The Golden
Years | 919
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.
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
2
the most common form of dementia. 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

Sons, Inc., 512.
Sons, Inc.,421.
920 | Older Adulthood: The Golden Years

lose an inch or two in height. Also, short-term memory might not
3
be as keen as it once was.
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.
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 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
3. McMillan, B. (2008). Illustrated Atlas of the Human

Body. Weldon Owen, 260.
Older Adulthood: The Golden Years | 921

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
digestive enzymes in 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
4
annually. 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.
4. Deaths and Mortality. Centers for Disease Control,

National Center for Health Statistics.
http://www.cdc.gov/nchs/fastats/deaths.htm. Updated
May 3, 2017. Accessed December 9, 2017.

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
5
may help to improve caloric intake. 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.
5. Morley, JE. (1997). Anorexia of Aging: Physiologic and

Pathologic. American Journal of Clinical Nutrition, 66,
760–73. http://www.ajcn.org/content/66/4/
760.full.pdf. Accessed November 12, 2017.

Vision Problems
Many older people suffer from vision problems and a loss of vision.
Age-related macular degeneration is the leading cause of blindness
6
in Americans over age sixty. 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,
7
and honeydew melon.
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

Sons, Inc., 413.
Sons, Inc., 415.

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
8
older.
8. Rivlin, RS. (2007). Keeping the Young-Elderly Healthy: Is

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
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
9
disease and hypertension, among other chronic conditions.
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.

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PART XVI
CHAPTER 16.
PERFORMANCE
NUTRITION
Chapter 16. Performance

Nutrition | 931
Introduction
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.
Haydenraml
erdesigns
Learning Objectives
Introduction | 933
• 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
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
http://www.ironman.com.
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
934 | Introduction
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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Introduction | 935
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
1
risk of cardiovascular disease. Strengthening your heart muscle
1. The American Heart Association Recommendations for

Physical Activity in Adults. American Heart Association.
Heart.org. http://www.heart.org/HEARTORG/
HealthyLiving/PhysicalActivity/FitnessBasics/
American-Heart-Association-Recommendations-for-
936 | The Essential Elements of
Physical Fitness
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 (O2) 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
2
over time with training.
Figure 16.1 VO2 Max Test
Physical-Activity-
Infographic_UCM_450754_SubHomePage.jsp. Accessed
March 10, 2018.
2. Ed Eyestone. How to Improve Your VO2 Max.
RunnersWorld.com. http://www.runnersworld.com/
article/0,7120,s6-238-244--12408-0,00.html. Published
January 9, 2008.
The Essential Elements of Physical Fitness | 937

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
938 | The Essential Elements of Physical Fitness

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
3
program.
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
4
deteriorate with age, which can result in falls and fractures.
Body Composition
Body composition is the proportion of fat and fat-free mass (which
3. American College of Sports Medicine. Resistance

Training for Health and Fitness. Acsm.org.
https://www.acsm.org/docs/brochures/resistance-
training.pdf. Accessed March 11, 2018.
4. Fitness Training: Elements of a Well-Rounded Routine.
MayoClinic.com. http://www.mayoclinic.com/health/
fitness-training/HQ01305. Updated August 10, 2017.

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
5
other hand range from 10 to 22 percent of body fat.
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
5. Measuring and Evaluating Body Composition. ACSM.org.

http://www.acsm.org/public-information/articles/
2016/10/07/measuring-and-evaluating-body-
composition

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 Effect of Physical Activity on Energy Expenditure”).
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.
Figure 16.2 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 https://health.gov/paguidelines/guidelines/adults.aspx
and the ACSM website at http://www.acsm.org/about-acsm/
media-room/news-releases/2011/08/01/acsm-issues-new-
recommendations-on-quantity-and-quality-of-exercise.

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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
1
minutes per week. 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
1. Physical Activity and Health: The Benefits of Physical

Activity. CDC.org. http://www.cdc.gov/physicalactivity/
everyone/health/index.html. Last updated February 16,
2011.
The Benefits of Physical
Activity | 945
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
946 | The Benefits of Physical Activity

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.
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,
The Benefits of Physical Activity | 947

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.
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948 | The Benefits of Physical Activity


The Benefits of Physical Activity | 949

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 “Anaerobic versus Aerobic Metabolism”, 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 16.3 Anaerobic versus Aerobic Metabolism
950 | Fuel Sources

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
Fuel Sources | 951

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 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 16.4 The Effect of Exercise Duration on Energy Systems
952 | Fuel Sources

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.
Figure 16.5 Fuel Sources for Anaerobic and Aerobic Metabolism
Fuel Sources | 953

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 “The Effect of
Exercise Intensity on Fuel Sources”). 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
954 | Fuel Sources

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 16.6 The Effect of Exercise Intensity on Fuel Sources
Image by
Allison
Calabrese /
CC BY 4.0
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
Fuel Sources | 955

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 froms 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.
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
956 | Fuel Sources

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.
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958 | Fuel Sources

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
Sports Nutrition | 959

are also able to burn more calories than women for the same activity
because they have more muscle mass which requires more energy
1
to support and move around.
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
2
athletes.
1. Nutrition and Athletic Performance. (2016). American

College of Sports Medicine. Medicine & Science in Sports
& Exercise, 48(3), 543- 568. https://journals.lww.com/
acsm-msse/Fulltext/2016/03000/
March 17, 2018.
March 17, 2018.
960 | Sports Nutrition

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
3
competition. See Table 16.1 “Daily Needs for Carbohydrate Fuel” for
carbohydrate needs for athletes depending on the intensity of the
exercise.
Table 16.1 Daily Needs for Carbohydrate Fuel
Increase of
Activity Carbohydrate (g/kg of
Example of Exercise
Level athlete’s body weight/
day)
Low intensity or skill based
Light 3-5
activities
Moderate exercise program
Moderate 5-7
(about 1 hour per day)
Endurance program (about 1-3
High hours per day of moderate to high 6-10
intensity exercise)
Extreme commitment (4-5 hours
Very
per day of moderate to high 8-12
High
intensity exercise)

March 17, 2018.

Source: Nutrition and Athletic Performance. American College of
Sports Medicine.Medicine & Science in Sports & Exercise. 2016;
48(3), 543- 568. https://journals.lww.com/acsm-msse/Fulltext/
2016/03000/Nutrition_and_Athletic_Performance.25.aspx.
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 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
4
vitamins and essential fatty acids, especially omega 3’s.
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
4. Nutrition and Athletic Performance. (2016), American

March 17, 2018.

5
or when reducing energy intake. See Table 16.2 “Recommended
Protein Intakes for Athletes” below for a better representation of
protein needs depending on extent of training and dietary sources.
Table 16.2 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.
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

March 17, 2018.

for vegetarian athletes. (See Table 16.2 “The Recommended Protein
Intakes for Individuals” )
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,
6
vitamin D, and some antioxidants.

March 17, 2018.

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 “Relative Energy Deficiency in Sport Effects”. 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.
Figure 16.7 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,
7
and eating disorders.
7. The Female Athlete Triad. (2016). American College of

Sports Medicine. http://www.acsm.org/public-
information/articles/2016/10/07/the-female-athlete-

Figure 16.8 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
8
greatest risk for developing iron deficiency. See Table 16.3 “The
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.

Potential Iron Loss in Endurance Athletes” 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 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 16.3 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 S.Exercise and iron status. J Nutr. 1992
Mar;122(3 Suppl):782-7. https://www.ncbi.nlm.nih.gov/pubmed/
1542048. 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
https://academic.oup.com/ajcn/article/72/2/594S/
4729672. Accessed March 16, 2018.

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
9
maintain sufficient vitamin D status.
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

March 17, 2018.

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.
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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 16.9 “Dehydration Effect on Exercise Performance”). It is
important to continue to consume water before, during and after
exercise to avoid dehydration as much as possible.
Figure 16.9 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
972 | Water and Electrolyte Needs

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 16.10
“The Heat Index”).
Figure 16.10 The Heat Index
Water and Electrolyte Needs | 973

“Heat Index”
by National
Weather
Service,
Southern
Region
Headquarter
s / 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 small.Drinking 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 16.11 “The Effect
of Exercise on Sodium Levels”). 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 16.11 The Effect of Exercise on Sodium Levels
Image by
Allison
Calabrese /
CC BY 4.0
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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
1
benefit from taking daily vitamin and mineral supplements:
• Women who are pregnant or breastfeeding

• Premenopausal women who may need extra calcium and iron
• Older adults

March 17, 2018.
Food Supplements and Food
Replacements | 977
• 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
2
to recognize possible drawbacks that are specific to each kind:
• 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.
2. Choosing a Vitamin and Mineral Supplement—Topic

Overview. WebMD.com. http://www.webmd.com/food-
recipes/tc/choosing-a-vitamin -and-mineral-
supplement-topic-overview. Last revised March 11, 2018.
978 | Food Supplements and Food Replacements

• 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
Food Supplements and Food Replacements | 979

3
FDA has proven that they are hazardous. 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 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
3. Watson S. How to Evaluate Vitamins and Supplements.

WebMD.com. http://www.webmd.com/vitamins-and-
supplements/lifestyle-guide -11/how-to-evaluate-
vitamins-supplements. Accessed March 11, 2018.

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
4
times higher than the deaths due to gun violence. 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.
4. Why Good Nutrition Is Important. CSPINET.org.

http://www.cspinet.org/nutritionpolicy/
nutrition_policy.html. Accessed March 9, 2018.

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PART XVII
CHAPTER 17. FOOD SAFETY
Chapter 17. Food Safety | 985

Introduction
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.
Image by
Maarten Van
de Heuvel on
unsplash.co
m / CCO
Learning Objectives
Introduction | 987
• 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
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
1
foodborne toxins in the egg sandwiches.
1. Thein CC, Trinidad RM, Pavlin B. (2010). A Large

Foodborne Outbreak on a Small Pacific Island. Pacific
988 | Introduction
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
2
contaminated foods or beverages. 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
Health Dialogue, 16(1). https://www.ncbi.nlm.nih.gov/

pubmed/20968238. Accessed January 28, 2018.
2. Foodborne Illnesses and Germs. (2018). Centers for
Disease Control and Prevention.https://www.cdc.gov/
foodsafety/foodborne-germs.html . Updated January 23,
2018. Accessed January 28, 2017.
Introduction | 989
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.
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990 | Introduction
Introduction | 991
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
992 | The Major Types of Foodborne

Illness
1
have been identified. 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
2
hepatitis A in China, which affected about 300,000 people.
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:

2. Food Safety. (2017). World Health Organization.
en/. Updated October 2017. Accessed January 18, 2018.
The Major Types of Foodborne Illness | 993

• 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
3
gastroenteritis and other kinds of foodborne illness. Like
pathogens, toxins and chemicals can be introduced to food during
cultivation, harvesting, processing, or distribution. Some toxins can
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.
https://wwwnc.cdc.gov/eid/article/17/1/
p2-1101_article. Accessed January 28, 2018.
994 | The Major Types of Foodborne Illness

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.
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The Major Types of Foodborne Illness | 995

996 | The Major Types of Foodborne Illness

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
The Causes of Food
Contamination | 997
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.
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
1
complications, such as a high fever and severe diarrhea.
1. Salmonella. (2018). Centers for Disease Control and
998 | The Causes of Food Contamination

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,
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
Prevention. http://www.cdc.gov/salmonella/. Updated

January 24, 2018. Accessed January 29, 2018.
The Causes of Food Contamination | 999

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
2
underlying health problems.


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 (see Figure 15.1 “Viruses in the Human
Body”). 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,
3
diarrhea, stomach pain, headache, and a low-grade fever.
Figure 17.1 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
4
acute infection can also lead to the disease.
Mold Toxins
Mold can grow on fruits, vegetables, grains, meats, poultry, and

dairy products, and typically appears as gray or green “fur.”
4. Centers for Disease Control and Prevention. (2010).

“Parasites.” Last updated November 2, 2010.
http://www.cdc.gov/parasites/food.html.

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
5
feed products.
5. Molds on Food: Are They Dangerous?.(2013). US

Department of Agriculture, Food Safety and Inspection
Service. https://www.fsis.usda.gov/wps/portal/fsis/
topics/food-safety-education/get-answers/food-
safety-fact-sheets/safe-food-handling/molds-on-food-
are-they-dangerous_/ct_index. Updated August 22,
2013. Accessed January 2018.

Poisonous Mushrooms
Amanita
Muscaria by
Onder
Wijsgek /
CC BY 3.0
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
6
between the edible and toxic kinds .
6. US Department of Agriculture, Food Safety and

Inspection Service. (2010). “Molds on Food: Are They
Dangerous?” Last modified March 4, 2010.
http://www.fsis.usda.gov/FactSheets/
Molds_On_Food/.

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,
7
cabbage, and broccoli. 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
7. Pesticide Residues in Food. (2018). World Health

Organization. http://www.who.int/mediacentre/
factsheets/pesticide-residues-food/en/. Updated
January 2018. Accessed January 28, 2018.

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
8
coordination.
8. Minamata Disease: The History and Measures. (2002).

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,
9
reproductive, nervous, and endocrine systems.
Learning Activities

Ministry of the Environment, Government of

Japan.http://www.env.go.jp/en/chemi/hs/
minamata2002/. Published 2002. Accessed December 21,
2011.
9. Learn About Polychlorinated Biphenyls. (2017).US
Environmental Protection Agency.
https://www.epa.gov/pcbs/learn-about-
polychlorinated-biphenyls-pcbs. Updated August 10,

Open Document).




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
1
monitoring how food is produced, processed, and packaged.
1. History of Food and Drug Regulation in the United

States. (2010). EH.Net Encyclopedia.
http://eh.net/?s=History+of+Food+and+Drug+Regulatio
Protecting the Public Health | 1011

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
2
to the recall of thousands of jars of a few popular brands. 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
3
hospitalizations. In January 2011, the Food Safety Modernization
n+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. http://www.fda.gov/ForConsumers/
ConsumerUpdates/ucm049070.htm. Updated
September 9, 2011. Accessed January 18, 2018.
3. Centers for Disease Control and Prevention. (2011).
“Multistate Outbreak of Listeriosis Associated with
1012 | Protecting the Public Health

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
pesticides.The EPA approves pesticides and other chemicals used
in agriculture, and sets limits on how much residue can remain
Jensen Farms Cantaloupe—United States.”

August–September, 2011. http://www.cdc.gov/mmwr/
preview/mmwrhtml/mm6039a5.htm?s_cid=
mm6039a5_w.

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
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

https://www.fsis.usda.gov/Oa/background/keyhaccp.htm.

Learning Activities

Open Document).



The Food System
Image by
Morten Just
/ CC BY-NC
3.0
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.
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
The Food System | 1017

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.
Learning Activities

Open Document).


1018 | The Food System

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.
Food Preservation | 1019

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
1020 | Food Preservation

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
• 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

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
1
the rules of basic food safety are not followed.
1. Food Irradiation. (2018). U.S. Food and Drug

Administration. https://www.fda.gov/food/

Learning Activities

Open Document).


resourcesforyou/consumers/ucm261680.htm. Updated
January 4, 2018. Accessed January 18, 2018.


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
Image by
Dean
Hochman /
CC BY 2.0
Food processing has a number of important benefits, such as
Food Processing | 1025

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
1
considered harmful.
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
2
prevent molds and yeast from growing on food. Food additives
1. Sugar and Carbohydrates. American Heart Association.

http://www.heart.org/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.
http://health.howstuffworks.com/wellness/food-
1026 | Food Processing

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 “Food
Additives” lists some common food additives and their uses:
Table 17.1 Food Additives
Additive Reason for Adding
Beta-carotene Adds artificial coloring to food
Caffeine Acts as a stimulant
Increases tartness to prevent food from

Citric acid
becoming rancid
Thickens gravies, sauces, and baking
Dextrin
mixes
Gelatin Stabilizes, thickens, or texturizes food
Keeps ingredients from separating and
Modified food starch
prevents lumps
MSG Enhances flavor in a variety of foods
Pectin Gives candies and jams a gel-like texture
Blends oil and water and keep them

Polysorbates
from separating
Emulsifies and stabilizes chocolate,

Soy lecithin
margarine, and other items
Sulfites Prevent discoloration in dried fruits

Thickens, emulsifies, and stabilizes dairy
Xanthan gum
products and dressings
Source: Chemical Cuisine: Learn about Food Additives. Center for

Science in the Public Interest.http://www.cspinet.org/reports/
chemcuisine.htm. Published 2012. Accessed January 20, 2018.
nutrition/facts/dangers-of-food -additives.htm.

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,
3
and chest pain in some individuals.
3. The Issues: Additives. Sustainable Table.

http://www.sustainabletable.org/issues/
additives/#fn14. Accessed October 10, 2011.
1028 | Food Processing

Learning Activities

Open Document).



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
1
About Food From Genetically Engineered Plants.
1. Foods from Genetically Engineered Plants. U.S. Food and

Drug Administration. https://www.fda.gov/food/
1030 | The Effect of New
Technologies
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
2
plants with desirable characteristics. 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
3
to grow that crop year-round.
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
ingredientspackaginglabeling/geplants/default.htm.
Updated January 4, 2018. Accessed January 20, 2018.
2. What Are Genetically Modified Foods?.
Genomics.Energy.gov. http://www.ornl.gov/sci/
techresources/Human_Genome/elsi/gmfood.shtml.
Last modified November 5, 2008. Accessed October 11,
2011.
3. Whitman DB. Genetically Modified Foods: Harmful or
Helpful?. CSA Discovery Guides. 2000; 1-13.
https://biomed.brown.edu/arise/resources/docs/
GM%20foods%20review.pdf. Accessed January 20, 2018.
The Effect of New Technologies | 1031

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
4
contamination of non-genetically engineered organisms.
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
5
reviewed by all three.
4. Food Safety: 20 Questions on Genetically Modified

Foods. World Health Organization. http://www.who.int/
foodsafety/publications/biotech/20questions/en/.
Updated May 2014. Accessed January 18, 2018.
5. Whitman DB. Genetically Modified Foods: Harmful or
Helpful?. CSA Discovery Guides. 2000; 1-13.
https://biomed.brown.edu/arise/resources/docs/
GM%20foods%20review.pdf. Accessed January 20, 2018.
1032 | The Effect of New Technologies

Learning Activities

Open Document).


The Effect of New Technologies | 1033

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
1
handling, preparing, and serving food are :
• 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
1. US Department of Health and Human Services. “Keep

Food Safe.” Food Safety.gov. Accessed December 21, 2011.
http://www.foodsafety.gov/keep/index.html.
1034 | Efforts on the Consumer
Level: What You Can Do
to check the website http://www.stilltasty.com, 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
Efforts on the Consumer Level: What You Can Do | 1035

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
2
thoroughly under running water to clean off pesticide residue .
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
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.
http://www.cdpr.ca.gov/docs/dept/factshts/residu2.
1036 | Efforts on the Consumer Level: What You Can Do

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.
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. Seafood should
be cooked to an internal temperature of 145°F, beef, lamb, and pork
to 160°F, ground chicken and turkey to 165°F, poultry breasts to
165°F, and whole poultry and thighs to 180°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.
Learning Activities

Open Document).


1038 | Efforts on the Consumer Level: What You Can Do



PART XVIII
CHAPTER 18.
NUTRITIONAL ISSUES
Chapter 18. Nutritional Issues | 1041

Introduction
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
“Earth in
Hand” Image
from flickr.co
m
Introduction | 1043
Learning Objectives
• 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 http://manoa.hawaii.edu/ctahr/
pacificfoodguide/index.php/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
1044 | Introduction
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.
Introduction | 1045
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
1
one’s quality of life. 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
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. https://mckinley.illinois.edu/health-
education/wellness. Accessed April 15, 2018.
1046 | Comparing Diets

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.
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
http://manoa.hawaii.edu/ctahr/pacificfoodguide/
index.php/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,
Comparing Diets | 1047

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,
2
medical foods, and special dietary use foods.
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.
2. Functional Foods. The Academy of Nutrition and

Dietetics. https://www.eatright.org/food/nutrition/
healthy-eating/functional-foods. Published July 5, 2018.
Accessed April 15, 2018.

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 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,
3
stroke, diabetes, osteoporosis, and certain cancers.
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
3. DASH Diet Eating Plan. DASH Diet Oregon.

http://www.dashdietoregon.org/. Accessed April 12,
2018.

LDL (bad) cholesterol, it still has a positive cumulative effect on
4
heart health.
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
4. DASH Diet Eating Plan. DASH Diet Oregon.

http://www.dashdietoregon.org/. Accessed April 12,
2018.

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
5
(i.e. okra, bok choy, carrots). 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
6
to grass-fed. Furthermore, the Paleo diet does not allow for dairy
foods while the Keto diet allows dairy foods without added sugar.
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
7
amount of weight lost on higher carbohydrate diets.
5. Paleolithic Nutrition — A Consideration of Its Nature and

Current Implications | NEJM. https://www-nejm-
org.eres.library.manoa.hawaii.edu/doi/full/10.1056/
NEJM198501313120505?url_ver=Z39.88-2003&rfr_id=ori
%3Arid%3Acrossref.org&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. http://www.mayoclinic.com/health/low-carb-
diet/NU00279. Accessed March 6, 2018.

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
8
evidence.
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
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.

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
9
also very low in essential vitamins and minerals.
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
9. Zelman, KM. Macrobiotic Diet.

http://www.webmd.com/diet/features/macrobiotic-
diet. Updated February 9, 2018. Accessed April 12, 2018.

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
10
levels significantly.
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
10. Robinson, K. The Mediterranean Diet.

http://www.webmd.com/diet/features/the-
mediterranean-diet. Published February 6, 2018.

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
11
favorite meal.
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
11. More Olive Oil in Diet Could Cut Stroke Risk: Study.
MedicineNet.com. https://www.medicinenet.com/
script/main/art.asp?articlekey=145823. Published 2011.
Accessed April 15,2018.

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
12
meats should always be cooked before eating.
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 U.S.By 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,
12. Raw Food Diet. WebMD.com.https://www.webmd.com/

diet/a-z/raw-foods-diet. Published November 21, 2016.

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 18.1 The Pros and Cons of Seven Popular Diets

Diet Pros Cons
• Recommended by the
National Heart, Lung,
and Blood Institute, the
American Heart
Association, and many • There are very few
physicians negative factors
• Helps to lower blood associated with the
DASH Diet
pressure and DASH diet
cholesterol • Risk
• Reduces risk of heart for hyponatremia
disease and stroke
• Reduces risk of certain
cancers
• Reduces diabetes risk
• Reduces the symptoms

of gluten intolerance,
such as chronic
• Risk of folate, iron,
diarrhea, cramping,
thiamin, riboflavin,
constipation, and
niacin, and vitamin
bloating
B6 deficiencies
• Promotes healing of the
• Special gluten-free
small intestines for
Gluten-Free products can be hard
people with celiac
Diet to find and expensive
disease, preventing
• Requires constant
malnutrition
vigilance and careful
• May be beneficial for
food label reading,
other autoimmune
since gluten is found
diseases, such as
in many products
Parkinson’s disease,
rheumatoid arthritis,
and multiple sclerosis
• Not entirely
evidence-based
• Restricts refined
• Results in higher fat
carbohydrates, such as
and protein
white flour and white
consumption
Low-Carb Diet sugar
• Does not meet the
• May temporarily
RDA for
improve blood sugar or
carbohydrates to
blood cholesterol levels
provide glucose to
the brain

• Not entirely
• Low in saturated fats evidence-based
and high in fiber • Lacks certain
• Emphasizes whole vitamins and
foods and minerals;
Macrobiotic de-emphasizes supplements are
Diet processed foods often required
• Rich in phytoestrogens, • Can result in a very
which may reduce the low caloric intake
risk of estrogen-related • Lack of energy may
cancers result from
inadequate protein
• A reduced risk of
cardiovascular disease
and mortality
• Does not specify
• A lower risk of cancer
daily serving
• De-emphasizes
amounts
processed foods and
• Potential for high fat
emphasizes whole
and high calorie
foods and healthy fats
intake as nuts and
• Lower sodium intake,
Mediterranean oils are calorie-dense
due to fewer processed
Diet foods
foods
• Drinking one to two
• Emphasis on
glasses of wine per
monosaturated fats
day may not be
leads to lower
healthy for those
cholesterol
with certain
• Highlighting fruits and
conditions
vegetables raises
consumption of
antioxidants
• Not entirely
evidence-based
• Very restrictive and
limits protein and
healthy fat intake
• Emphasizes whole
• Could encourage the
foods
Raw Food Diet development of
• Focuses on
foodborne illness
nutritionally-rich foods
• 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 such as protein, iron,
chronic diseases such zinc, omega-3,
as cancer, heart vitamin B12
Vegetarianism disease, and Type 2 • Consumption of a
and Veganism diabetes high fiber diet
• May help with weight interferes with
reduction and weight mineral and nutrient
maintenance bioavailability
• Vegetarian and vegan
protein sources are
lower quality with
majority missing at
least one essential
amino acids
Learning Activities

Open Document).





1. Calories In Versus Calories
Out
Image by
mojzagrebinf
o / Pixabay
License
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.
Calories In Versus Calories

Out | 1063
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
1
billion dollar value to the weight loss market. 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
234
of future weight gain and onset of obesity. Meta-analysis and
1. The U.S. weight loss & diet control market. (2019).

Marketdata LLC.
https://www.researchandmarkets.com/research/
qm2gts/the_72_billion?w=4
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.
1064 | Calories In Versus Calories Out

reviews of randomized clinical trials reported that on average,
56
obesity treatments cause weight gain. 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
7
aspects of treatment. 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.
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.
Calories In Versus Calories Out | 1065

Dieting and Health
Image by
Kellie
Taguchi /
CC BY 4.0
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.
The majority (up to 95%) of people regain the weight within three
89
years and often gain back more. 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
1011
for eating disorders. Dieting and weight cycling also have a
negative impact on mental health including lower self-esteem, and
12
increases in depression, anxiety, irritability, and nervousness.
The evidence shows that dieting reduces both physical and
emotional health.
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.

Health and Body Weight
Image by
272447 /
Pixabay
License
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”.

1314151617
The results of multiple studies have indicated that using
weight as a criterion for health is off-target and potentially
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.

181920
harmful. This suggests that it is not possible to tell how
healthy an individual is simply by looking at them or calculating
their BMI.
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.
• 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
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.

• 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
21
promote a better quality of life. 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
22
HAES group sustained their health improvements”.
21. Association for Size Diversity and Health. (2020). HAES

Principles. www.sizediversityandhealth.org
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.

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,

23
and harmony”. 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.
23. Ulukau Hawaiian Electronic Library.

http://wehewehe.org/

Image by
Jennifer
Draper / CC
BY 4.0
Intuitive Eating
Image by
CDC /
Unsplash
License
Intuitive eating is a non-diet approach to eating that promotes a

connection to body cues of hunger and fullness and the selection
24
of foods based on both pleasure and nutrient density. 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
25
improve psychological distress. 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
26
blood pressure and cholesterol levels, and dietary intake.
24. The Original Intuitive Eating Pros. (2007 - 2019). 10

Principles of Intuitive Eating.
https://www.intuitiveeating.org/10-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.

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
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

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
1076 | Nutrition, Health and Disease

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
1
obese. 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,
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. http://www.ncbi.nlm.nih.gov/
pubmed/16061918. Accessed April 12, 2018.
Nutrition, Health and Disease | 1077

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 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
• 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
2
separate entities.
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 18.1 Gingivitis
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.
https://www.ncbi.nlm.nih.gov/books/NBK47472/.

“Gingivitis”
/ CC0 1.0
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
3
children in this country have at least one cavity.
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
4
sugars, is significantly associated with increased dental caries risk.”
In regards to sugary soft drinks, the American Dental Association
says that drinking sugary soft drinks increases the risk of decay
5
formation.
3. Continuing MCH Education in Oral Health. Oral Health

and Health Care. http://ccnmtl.columbia.edu/projects/
otm/index.html. 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.
PMC2862385/. Accessed April 15, 2018.
5. Foods that Affects your Teeth. American Dental

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
6
the age of sixty have the disorder. Ten to 25 percent of people
7
who have diverticulosis go on to develop diverticulitis. Symptoms
include lower abdominal pain, nausea, and alternating between
constipation and diarrhea.
The chances of developing diverticulosis can be reduced with
Association. https://www.mouthhealthy.org/en/
nutrition/food-tips. Accessed April 15, 2018.
6. Diverticular Disease. National Institute of Diabetes and
Digestive and Kidney Diseases, National Institute of
Health. http://digestive.niddk.nih.gov/ddiseases/pubs/
diverticulosis/. Accessed April 15, 2018.
7. Diverticular Disease. National Institute of Diabetes and
Digestive and Kidney Diseases, National Institute of
Health. http://digestive.niddk.nih.gov/ddiseases/pubs/
diverticulosis/. Accessed April 15, 2018.

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 18.2 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
8
associated with a reduction in colon cancer risk. 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.
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,
9
which is lower-than-normal bone mineral density.
8. Park Y, Hunter DJ. (2005). Dietary Fiber Intake and Risk

of Colorectal Cancer. Journal of the American Medical
Association, 294(22), 2849–57.
Accessed April 15,2018.
9. Office of the Surgeon General (US). Bone Health and

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
10
disease.
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
Osteoporosis. 2004. https://www.ncbi.nlm.nih.gov/

books/NBK45513/. Accessed April 12,2018.
10. Facts and Statistics. International Osteoporosis
Foundation. https://www.iof bonehealth.org/facts-
statistics#category-14. Accessed March 17, 2018.

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
11
caused by osteoporosis.
Figure 18.3 Osteoporosis in Vertebrae
11. Osteoporosis. American Academy of Orthopaedic

Surgeons.OrthoInfo. http://orthoinfo.aaos.org/
topic.cfm?topic=a00232. Updated August 2009.

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.
Image by
Tomasz
Sienick / CC
BY- SA 3.0
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 fitness.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.
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

12
develop osteoporosis and sometimes it occurs very early in life.
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
13
hip fractures.
12. Mehler PS, Weiner K. The Risk of Osteoporosis in

Anorexia Nervosa. Eating Disorders Recovery Today.
http://www.eatingdisordersrecoverytoday.com/the-
risk-of-osteoporosis-in-anorexia-nervosa/. 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. http://www.ncbi.nlm.nih.gov/
pubmed/9353503. Accessed April 15, 2018.

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
14
both men and women. 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.
14. New IOF Report Shows Smoking, Alcohol, Being

Underweight, and Poor Nutrition Harm Our Bones.
International Osteoporosis Foundation.
https://www.iof bonehealth.org/new-iof-report-shows-
smoking-alcohol-being-underweight-and-poor-
nutrition-harm-our-bones. Published October 19, 2007.

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 role in maximizing
bone health and there is little consistent evidence that suggests
high protein diets negatively affect bone health when calcium intake
15
is adequate.
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
15. Heaney, RP, Layman DK. (2008). Amount and Type of

Protein Influences Bone Health. The American Journal of
Clinical Nutrition, 87(5), 1567S–70S.
http://www.ajcn.org/content/87/5/1567S.long.

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
16
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
• Men fifty to sixty-nine years of age with risk factors
Learning Activities

16. Bone Density Exam/Test. National Osteoporosis

Foundation. https://www.nof.org/patients/diagnosis-
information/bone-density-examtesting/. Accessed
April 15, 2018.

Open Document).




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
1098 | Threats to Health

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
Threats to Health | 1099

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
1
and dairy products.
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
1. Overweight and Obesity Statistics.National Institute of

Diabetes and Digestive and Kidney Diseases.
https://www.niddk.nih.gov/health-information/health-
statistics/overweight-obesity. Accessed April 15, 2018.

the Centers for Disease Control and Prevention (CDC), heart disease
2
is the leading cause of death in the United States.
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 18.2 The Risk Factors for Cardiovascular Disease
2. Leading Causes of Death. CDC.gov.

https://www.cdc.gov/nchs/fastats/leading-causes-of-
death.htm. Updated March 17, 2017. Accessed April 15,
2018.

Unmodifiable
Modifiable Risk Factors
Risk Factors
• Age. Risk
increases for
men at
forty-five,
• Cigarette smoking. Nicotine constricts blood
and for
vessels, and carbon monoxide damages their
women at
inner lining, which increases the risk of
fifty-five.
atherosclerosis.
• Sex. Men
• Obesity. Excess weight worsens other risk
have a higher
factors.
risk than
• Diabetes. This condition is associated with an
women,
increased risk of heart disease. Both types have
though the
certain risk factors in common, including obesity
risk for
and high blood pressure.
women
• Physical inactivity. Lack of exercise is associated
steeply rises
with heart disease.
after
• Cholesterol levels. High levels of blood
menopause.
cholesterol can increase the risk. A high level of
• Family
low-density lipoprotein (LDL), or the “bad”
history. The
cholesterol, is a common contributing factor.
more family
However, a low level of high-density lipoprotein
members
(HDL), or “good” cholesterol, can also promote
who have
atherosclerosis.
heart
disease, the
greater the
risk.
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
3
United States. 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

• Prehypertension. Higher than 120 over 80 and lower than 139
over 89
• Hypertension. Greater than 139 over 89
Table 18.3 The Risk Factors for Hypertension
3. High Blood Pressure Facts. Center for Disease Control

and Prevention. https://www.cdc.gov/bloodpressure/
facts.htm. Updated April 5, 2018. Accessed April 15, 2018.

Unmodifiable Risk Factors Modifiable Risk Factors
• Weight. Roughly 60
percent of people with
hypertension are obese.
• Sodium consumption.
• Age. After fifty-five, the risk of
The more salt in a
developing high blood pressure is 90
person’s diet, the more
percent.
likely they are to have
• Race. African-Americans are more
high blood pressure.
likely to develop hypertension,
• Alcohol. Drinking more
manifest it at a younger age, and
than two drinks per day
have higher blood pressure readings.
for men and one drink
• Family history. There is a strong
for women increases the
genetic component to high blood
likelihood of
pressure, and an individual’s risk
hypertension.
goes up along with the number of
• Diet. In addition to salt
family members who have
and alcohol
hypertension.
consumption, other
dietary 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
4
and exposures that are known or suspected to cause cancer. The
National Institutes of Health has classified fifty-four different
5
compounds as known cancer-causing agents in humans.
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
4. Known and Probable Human Carcinogens. American

Cancer Society.http://www.cancer.org/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?. https://www.scientificamerican.com/
article/how-many-cancers-are-caused-by-the-
environment. Published May 10, 2010. Accessed April 15,
2018.

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 18.4 “The Risk Factors for
Cancer” shows some common risk factors for a number of different
types of cancer.
Table 18.4 The Risk Factors for Cancer

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,
• Age. Most cancers
and preparing meat at high
occur in people over
temperatures forms carcinogens.
the age of sixty-five.
• Red meat. The risk of colon cancer
However, people of all
seems to increase with the
ages, including
consumption of red meat and
children, can get
processed meat.
cancer.
• Cured meats. According to a recent
• Family history.
study, there is a mild risk of pancreatic
Certain types of
cancer with the consumption of cured
cancer have a genetic
meats, such as sausage, pepperoni,
link. However,
bacon, ham, smoked turkey, salami, and
environmental factors
hot dogs.
may also play a part.
• 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

6
form of cancer in their lifetime. 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-
7
based diet.
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.
6. What Is Cancer? American Cancer Society.

http://www.cancer.org/Cancer/CancerBasics/what-is-
cancer. Updated December 8, 2015. Accessed April 15,
2018.
7. Cancer Prevention and Early Detection Facts and Figures
2013. American Cancer Society.
https://www.cancer.org/content/dam/cancer-org/
research/cancer-facts-and-statistics/cancer-
prevention-and-early-detection-facts-and-figures/
cancer-prevention-and-early-detection-facts-and-
figures-2013.pdf. Published 2013. Accessed April 15, 2018.

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
8
common kinds of cancer.
Diabetes
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.
8. Cancer Prevention: 7 Steps to Reduce Your Risk. Mayo

Clinic. http://www.mayoclinic.com/health/cancer
-prevention/CA00024. Updated November 29, 2017.

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 “Healthy
Individuals and Type 2 Diabetes” . 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.
Figure 18.4 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
9
percent of the population. In 2007 the cost of diabetes to the
10
United States was estimated at $174 billion. 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
9. Diabetes Research and Statistics.Centers for Disease

Control and Prevention. https://www.cdc.gov/diabetes/
data/index.html. Updated March 14, 2018. Accessed
April 15, 2018.
10. Diabetes Quick Facts. Centers for Disease Control and
Prevention. https://www.cdc.gov/diabetes/basics/
quick-facts.html. Updated July 24, 2017. Accessed April
15, 2018.

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
11
percent.
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
12
Type 2 diabetes within the next ten years. 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.
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.
http://www.nejm.org/doi/full/10.1056/NEJMoa012512.
12. Diabetes Overview. National Institute of Diabetes and
Digestive and Kidney Disease.
https://www.niddk.nih.gov/health-information/
diabetes/overview. Accessed April 15, 2018.

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
13
and cardiovascular disease. 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
14
prediabetes.
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
15
of developing Type 2 diabetes.
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.
Figure 18.5 Metabolic Syndrome: A Combination of Risk Factors
Increasing the Chances for Chronic Disease
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.
http://www.nejm.org/doi/full/10.1056/NEJMoa012512.

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
16
greater than 100 mg/dL. The IDF estimates that between 20 and
16. The IDF Consensus Worldwide Definition of the

Metabolic Syndrome. International Diabetes
Federation.https://www.idf.org/our-activities/
advocacy-awareness/resources-and-tools/

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
17
do not have the syndrome.
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 http://www.pihoa.org/fullsite/
newsroom/wp-content/uploads/downloads/2012/06/
NCD_Emergency_Declaration.pdf
60:idfconsensus-worldwide-definitionof-the-metabolic-
syndrome.html. Accessed April 15, 2018.
17. The IDF Consensus Worldwide Definition of the
Metabolic Syndrome. International Diabetes
Federation.https://www.idf.org/our-activities/
advocacy-awareness/resources-and-tools/
60:idfconsensus-worldwide-definitionof-the-metabolic-
syndrome.html. Accessed April 15, 2018.

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.
Learning Activities

Open Document).



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.
Undernutrition, Overnutrition, and

Malnutrition | 1121
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
1
children and adolescents in the United States are underweight.
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
1. Prevalence of Underweight among Children and

Adolescents: United States, 2003–2006. Centers for
Disease Control and Prevention. http://www.cdc.gov/
nchs/data/hestat/underweight/
underweight_children.htm. Updated November 6, 2015.
1122 | Undernutrition, Overnutrition, and Malnutrition

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
2
example of how an unbalanced diet can affect health.
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
2. Eating Disorders. The National Institute of Mental

Health. https://www.nimh.nih.gov/health/statistics/
eating-disorders.shtml#part_155061. Accessed April 15,
2018.
Undernutrition, Overnutrition, and Malnutrition | 1123

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 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
3
otherwise known as bulimia, at some point in their lifetime.
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

2018.

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

4
lifetime. Treatment often involves antidepressant medication as
well as nutritional and psychiatric counseling.
Orthorexia Nervosa
Orthorexia nervosa was coined in 1997 by physician Steven

5
Bratman. The term uses “ortho,” in its meaning as straight, correct
6
and true and refers to a fixation on eating proper food. 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

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
https://www.orthorexia.com/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.

an incessant fear of weight gain but instead have an obsession with
7
“feeling pure, healthy and natural.” People affected by orthorexia
nervosa tend to follow diets tied to a philosophy or theory and
89
believe that their theory of eating is the best. Such diets often
have a redemptive quality that involves denying oneself of “bad” or
10
“wrong” foods. 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.
7. Mathieu J. (2005). What is orthorexia? Journal of the

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.
https://www.nationaleatingdisorders.org/learn/by-
eating-disorder/other/orthorexia
10. Mathieu J. (2005). What is orthorexia? Journal of the
essay/.

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
11
weight restoration as needed. OCD may be a consequence of
malnutrition, being underweight and a starved brain thus weight
restoration may resolve the OCD.
12
Warning signs and symptoms of orthorexia nervosa:
• Compulsive checking of ingredients lists and nutritional labels

• 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
13
following nutrients are important for proper healing:
• 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.
13. MacKay D, Miller AL. (2003). Nutritional Support for

Wound Healing. Alternative Medicine Review, 8(4),
14653765. Accessed April 15, 2018.

Learning Activities

Open Document).




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
1132 | Food Insecurity

of food. The economic crisis of 2008 caused a dramatic increase in
1
hunger across the United States.
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.
1. Hunger in America: 2016 United States Hunger and

Poverty Facts. World Hunger Education Service.
Retrieved from http://www.worldhunger.org/articles/
Learn/us_hunger_facts.htm. Accessed April 15, 2018.
Food Insecurity | 1133

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
2
have reported only a few instances of reduced food intake, if any.
African American and Hispanic households experience food
3
insecurity at much higher rates than the national average.
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
2. Coleman-Jensen A. Household Food Security in the

United States in 2010. US Department of Agriculture,
Economic Research Report, no. ERR-125. 2011.
https://www.ers.usda.gov/publications/pub-
details/?pubid=44909. Accessed April 15, 2018.

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
4
mineral intake. 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,
5
hurricanes, and other natural and man-made catastrophes.
4. Hunger in America: 2016 United States Hunger and

Poverty Facts. World Hunger Education Service.
Retrieved from http://www.worldhunger.org/articles/
Learn/us_hunger_facts.htm. Accessed April 15, 2018.
5. SOFI: Questions and Answers. Food and Agriculture
Organization of the United Nations.
http://www.fao.org/3/a-BT851E.pdf. Accessed April 15,
208.

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
6
citizens in the United States face the threat of hunger.
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
7
cities saw an increase in the number of homeless families. 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
8
at least part of the year hungry. Hunger delays their growth and
6. About Meals on Wheels. Meals on Wheels.

https://www.mealsonwheelsamerica.org/signup/
aboutmealsonwheels. 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.
https://endhomelessness.atavist.com/
mayorsreport2016. Accessed April 15, 2018.

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
9
pneumonia.
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

9. 2011 World Hunger and Poverty Facts and Statistics.
World Hunger Education
Service.https://www.worldhunger.org/articles/Learn/
old/world%20hunger%20facts%202002in2011.htm.

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
10
initiatives aimed at reducing food insecurity.
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


11
in the United States. 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
12
were $68.2 billion.
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
13
person.
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
14
schools and residential child-care institutions. 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

14. National School Lunch Program. US Department of
Agriculture. https://www.fns.usda.gov/nslp/national-
school-lunch-program-nslp. Accessed April 15, 2018.

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
15
citizen community.
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.
15. The Problem and Our Solution. Meals on Wheels.

https://www.mealsonwheelsamerica.org/theissue/
problemandsolution. Accessed April 15, 2018.

Learning Activities

Open Document).



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
Careers in Nutrition | 1143

1
that regulate this profession. Go to https://www.cdrnet.org/
certifications 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
1. Dietitians and Nutritionists. Bureau of Labor Statistics.

Occupational Outlook Handbook, 2010-11 Edition.
https://www.bls.gov/ooh/healthcare/dietitians-and-
nutritionists.htm. Updated April 13, 2018. Accessed April
15, 2018.
1144 | Careers in Nutrition

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 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.
Learning Activities
1146 | Careers in Nutrition

Open Document).




PART XIX
APPENDICES
Appendices | 1149
Appendix A
Appendix A
This table compares the typical levels of recommended daily

nutrient intake to the United States Tolerable Upper Intake Levels
(ULs) and the United Kingdom’s Safe Upper Levels (SULs). The
Recommended Dietary Allowance (RDA) and Adequate Intake (AI)
values are considered to be levels of nutrient intake that meet or
exceed the needs of practically all healthy people. The Daily Value
amounts, that are currently used as reference values on food and
supplement labels, are similar to the RDA/AI values, but differ in
some cases. UL values are the amounts that are considered to be the
maximum safe level of intake from food and supplements combined.
SUL values are the maximum level of intake of a nutrient from
dietary supplements that can be considered to be reasonably safe.
How much is too much?
Comparison of Dietary Reference Intake Values (for adult men and

women) and Daily Values for Micronutrients with the Tolerable
Upper Intake Levels (UL),a,c Safe Upper Levels (SUL),d and Guidance
Levelsd
Appendix A | 1151
RDA/
AIb Daily
SUL or Selected Potential
(men / Value
Nutrient ULc Guidance Effects of Excess
women) (Food
Leveld Intake
ages Labels)
31-50
Liver damage, bone
1500
Vitamin A 900 / 1500** & joint pain, dry
(5000 3000
(mcg) 700 (5000 IU) skin, loss of hair,
IU)
headache, vomiting
Increased risk of
lung cancer in
beta-Carotene 7 (11,655
– – – smokers and those
(mg) IU)
heavily exposed to
asbestos
Calcification of
10 brain, arteries,
Vitamin D 15 (600 25 (1000
(400 100 increased blood
(mcg) IU) IU)
IU) calcium, loss of
appetite, nausea
20 (30 540 (800 Deficient blood

Vitamin E (mg) 15 1000
IU) IU) clotting
Red blood cell
Vitamin K 120 /
80 – 1000** damage/anemia;
(mcg) 90*
liver damage
Headache, nausea,
irritability,
Thiamin (B1)
1.2 / 1.1 1.5 – 100** insomnia, rapid
(mg)
pulse, weakness
(7000+ mg dose)
Generally
considered
Riboflavin (B2)
1.3 / 1.1 1.7 – 40** harmless; yellow
(mg)
discoloration of
urine
Liver damage,
flushing, nausea,
Niacin (mg) 16 / 14 20 35 500**
gastrointestinal
problems
Neurological
Vitamin B6 problems,
1.3 2 100 10
(mg) numbness and pain
in limbs
Vitamin B12
2.4 6 – 2000**
(mcg)
1152 | Appendix A
Masks B12
deficiency (which
Folic acid
400 400 1000 1000** can cause
(mcg)
neurological
problems)
Diarrhea &
Pantothenic gastrointestinal
5* 10 – 200**
acid (mg) disturbance
(10,000+ mg/day)
No reports of
Biotin (mcg) 30* 300 – 900** toxicity from oral
ingestion
Fishy body odor
550/
Choline (mcg) – 3500 – (trimethylaminuria),
425*
hepatotoxicity
Vitamin C Nausea, diarrhea,
90 / 75 60 2000 1000**
(mg) kidney stones
Adverse effects on
male and female
Boron (mg) – – 20 9.6
reproductive
system
Nausea,
Calcium (mg) 1000 1000 2500 1500** constipation,
kidney stones
Increased blood
pressure in
salt-sensitive
Chloride (mg) 2300* 3400 3600 –
individuals (when
consumed as
sodium chloride)
Potential adverse
effects on liver and
Chromium
35/25* 120 – 10,000** kidneys; picolinate
(mcg)
form possibly
mutagenic
Cardiotoxic effects;
not appropriate in a
Cobalt (mg) – – – 1.4** dietary supplement
except as vitamin
B-12
Gastrointestinal
Copper (mcg) 900 2000 10000 10000 distress, liver
damage
Appendix A | 1153
Bone, kidney,
muscle, and nerve
damage;
Fluoride (mg) 4 / 3* – 10 –
supplement with
professional
guidance
Kidney toxin;
Germanium – – – zero** should not be in a
dietary supplement
Elevated thyroid
Iodine (mcg) 150 150 1100 500** hormone
concentration
Gastrointestinal
distress, increased
Iron (mg) 8 / 18 18 45 17** risk of heart
disease, oxidative
stress
Magnesium 420 /
400 350e 400** Diarrhea
(mg) 320
Manganese 2.3 /
2 11 4** Neurotoxicity
(mg) 1.8*
Gout-like
Molybdenum symptom; joint
45 75 2000 zero**
(mcg) pains; increased
uric acid
Increased
sensitivity of skin
Nickel (mcg) – – 1000 260**
reaction to nickel
in jewelry
Alteration of
parathyroid
Phosphorus
700 1000 4000 250** hormone levels;
(mg)
reduced bone
mineral density
Potassium Gastrointestinal
4700* 3500 – 3700**
(mg) damage
Nausea, diarrhea,
Selenium
55 70 400 450 fatigue, hair and
(mcg)
nail loss
Low toxicity;
Silicon (mg) – – – 700 possibility of
kidney stones
1154 | Appendix A
Increased blood
pressure in
salt-sensitive
Sodium (mg) 1500* 2400 2300 –
individuals (when
consumed as
sodium chloride)
Vanadium Gastrointestinal
– – 1.8 zero
(mg) irritation; fatigue
Impaired immune
Zinc (mg) 11 / 8 15 40 25 function, low
HDL-cholesterol
a
Food and Nutrition Board, Institute of Medicine (U.S.). Dietary
Reference Intakes Tables.
b
(RDA) = Recommended Dietary Allowance, AI = Adequate Intake,
indicated with *
c
UL = Tolerable Upper Intake Level (from food & supplements
combined)
d
SUL = Safe Upper Levels; SULs and Guidance Levels (indicated
by **) set by the Expert Group on Vitamins and Minerals of the Food
Standards Agency, United Kingdom. These are intended to be levels
of daily intake of nutrients in dietary supplements that potentially
susceptible individuals could take daily on a life-long basis without
medical supervision in reasonable safety. When the evidence base
was considered inadequate to set a SUL, Guidance Levels were
set based on limited data. SULs and Guidance Levels tend to be
conservative and it is possible that, for some vitamins and minerals,
greater amounts could be consumed for short periods without risk
to health. The values presented are for a 60 kg (132 lb) adult. Consult
the full publication for values expressed per kg body weight. This
FSA publication, Safe Upper Levels for Vitamins and Minerals, is
available at: http://www.foodstandards.gov.uk/multimedia/pdfs/
vitmin2003.pdf
e
The UL for magnesium represents intake specifically from
pharmacological agents and/or dietary supplements in addition to
dietary intake.
Appendix A | 1155
Appendix B
Attributions
Figures
1. Figure 2.5 The Human Digestive System reused “Digestive

system without labels” by Mariana Ruiz / Public Domain
2. Figure 2.6 Peristalsis in the Esophagus reused “Peristalsis” by
OpenStax College / CC BY 3.0
3. Figure 2.9 The Absorption of Nutrients reused “ “Digestive
system without labels” by Mariana Ruiz / Public Domain;
“Simple columnar epithelial cells” by McortNGHH / CC BY 3.0
4. Figure 2.28 Body Composition reused “Male body silhouette”
by mlampret / Public Domain
5. Figure 2.32 Fat Distribution reused “Body shapes” by Succubus
MacAstaroth / Public Domain; “Simple red apple” by Sanja /
Public Domain; “Pear” by Mrallowski / Public Domain
6. Figure 3.2 Distribution of Body Water reused “Male body
silhouette” by mlampret / Public Domain
7. Figure 3.6 Regulating Water Intake reused “Female silhouette”
by Pnx / Public Domain; “Water bottle” by Jonata / Public
Domain
8. Figure 3.7 Regulating Water Output reused “Hypophyse” by
Patrick J. Lynch / CC BY-SA 3.0; “Kidney-reins” by Belcirelk /
Public Domain
9. Figure 4.3 The Most Common Disaccharides reused “Three
important disaccharides” by OpenStax Anatomy and
Physiology / CC BY 4.0; “Roll bread” by StymShinji / Public
1156 | Attributions
Domain; “Bag of sugar” by Evilestmark / Public Domain; “Drink
milk butterfly” by Glitch / Public Domain
10. Figure 4.5 Dietary Fiber reused “Apples” by gnokii / Public
Domain; “Wheat kernel nutrition” by Jon C / CC BY-SA 3.0
11. Figure 4.8 The Regulation of Glucose reused “Pancreas organ”
by Zachvanstone8 / CC0; “Liver” by Maritacovarrubias /
Public Domain; “Muscle types” by Bruce Balus / CC BY-SA 4.0
12. Figure 4.9 Overview of Carbohydrate Digestion reused
“Digestive system without labels” by Mariana Ruiz / Public
Domain
13. Figure 5.1 Types of Lipids reused “Corn” by gnokii / Public
Domain; “Cheese” by gnokii / Public Domain; “Drink milk
butterfly” by Glitch / Public Domain; “Walnut” by Firkin /
Public Domain; “Olive oil” by gnokii / Public Domain
14. Figure 5.10 Lipid Digestion and Absorption reused “Digestive
system without labels” by Mariana Ruiz / Public Domain;
“Simple columnar epithelial cells” by McortNGHH / CC BY 3.0
15. Figure 5.13 Cholesterol and Soluble Fiber reused “Liver” by
Maritacovarrubias / Public Domain; “Stomach anatomy” by
Clker-free-vector-images / CC0; “Organs of the human body”
by Mothsart / Public Domain
16. Figure 6.7 Digestion and Absorption of Protein reused
“Digestive system without labels” by Mariana Ruiz / Public
Domain
17. Figure 6.10 Enzymes Role in Carbohydrate Digestion reused
“Bread” by Jack7 / Public Domain
18. Figure 7.1 Alcohol Metabolism Summary reused “Wine
Wineglass Beverage” by Clker-Free-Vector-Images / Pixabay
License
19. Figure 7.1 Alcohol Metabolism Summary reused “Osmotic
pressure on blood cells diagram” by Mariana Ruiz / Public
Domain
20. Figure 8.1 Lava erupting from the Puʻu ʻŌʻō vent in June 1983
by G.E. Ulrich, USGS / Public Domain
21. Figure 9.2 Absorption of Fat-Soluble and Water-Soluble
Attributions | 1157
Vitamins reused “Digestive system without labels” by Mariana
Ruiz / Public Domain; “Simple columnar epithelial cells” by
McortNGHH / CC BY 3.0
22. Figure 9.5 The Functions of Vitamin D reused “Female
silhouette” by Pnx / Public Domain; “Liver” by
Maritacovarrubias / Public Domain; “Kidney-reins” by
Belcirelk / Public Domain; “Organs of the human body” by
Mothsart / Public Domain; “A human humerus arm bone” by
kephalian_cosmos/ Public Domain; “Sun” by Puren / Public
Domain
23. Figure 9.10 The Role of Thiamin reused “Beta-D
Glucopryranose” by Neurotiker / Public Domain
24. Figure 9.12 Conversion of Tryptophan to Niacin reused
“Chicken with potatoes” by Machovka / Public Domain
25. Figure 9.17 Folate and the Formation of Macrocytic Anemia
reused “Diagram showing the development of different blood
cells from haematopoietic stem cells to mature cells” by Mikael
Haggstrom / CC BY-SA 3.0; “Red blood cell” by Database
Center for Life Science / CC BY 3.0
26. Figure 9.21 Antioxidants Role reused “DNA icon double
stranded” by Mcmurryjulie / CC0
27. Figure 10.2 Maintaining Blood Calcium Levels reused “Kidney-
reins” by Belcirelk / Public Domain; “A human humerus arm
bone” by kephalian_cosmos/ Public Domain
28. Figure 11.3 Iron Absorption, Functions, and Loss reused “Simple
columnar epithelial cells” by McortNGHH / CC BY 3.0; “A
human humerus arm bone” by kephalian_cosmos/ Public
Domain; “Red blood cell” by Database Center for Life Science
/ CC BY 3.0; “Liver” by Maritacovarrubias / Public Domain
29. Figure 14.2 “Student Teacher” by Peter Hershey / Unsplash
License
30. Figure 14.3 “Teenager Playing American Football” by Riley
McCullough / Unsplash License
31. Figure 15.1 reused “Silohuette of Three People” by photo-
nic.co.uk nic / Unsplash License
1158 | Attributions
32. Figure 15.2 reused “Two Women Riding Bikes” by David Marcu/
Unsplash License
33. Figure 15. reused “Man wearing blue shirt standing on white
surf board” by Alex Blajan / Unsplash License
34. Figure 16.3 Anaerobic versus Aerobic Metabolism by Allison
Calabrese / CC BY 4.0
35. Figure 16.4 The Effect of Exercise Duration on Energy Systems”
by Allison Calabrese / CC BY 4.0
36. Figure 16.5 “Fuel Sources for Anaerobic and Aerobic
Metabolism reused “Liver” by Maritacovarrubias / Public
Domain; “Bread” by Jack7 / Public Domain; “Muscle types” by
Bruce Balus / CC BY-SA 4.0; “Tango style chicken leg” by
Rugby471 / Public Domain; “Male body silhouette” by mlampret
/ Public Domain
37. Figure 16.6 The Effect of Exercise Intensity on Fuel Sources
reused “Happy reading guy” from Max Pixel / CC0; “Surfers
surfing waters” by hhach / CC0; “Football runner ball” by
Skeeze / CC0
38. Figure 16.7 Relative Energy Deficiency in Sport Effects reused
woman running icon by chelsey832 / Public Domain; Full
english breakfast by OgreofWart / Public Domain
39. Figure 16.11 The Effect of Exercise on Sodium Levels reused
male body silhouette by mlampret / Public Domain
40. Figure 17.1 Viruses in the Human Body reused “Simple columnar
epithelial cells” by McortNGHH / CC BY 3.0
Exercise Images
1. Exercise 2.1 reused “Digestive system without labels” by

Mariana Ruiz / Public Domain
2. Exercise 2.2a reused “Major Endocrine Glands” by National
Cancer Institute / Public Domain
3. Exercise 2.2a reused “Simplified diagram of the human
Attributions | 1159
Circulatory system in anterior view” by Mariana Ruiz / Public
Domain
4. Exercise 2.2a reused Nervous System” by William Crochot / CC
BY-SA 4.0
5. Exercise 2.2a reused “Human Respiratory System” by United
States National Institute of Health: National Heart, Lung and
Blood Institute / Public Domain
6. Exercise 2.2a reused “Digestive System” by Allison Calabrese /
CC BY 4.0
7. Exercise 2.2b reused “Urinary System” by Thstehle / Public
Domain
8. Exercise 2.2b reused “Integumentary System” by US-Gov
/Public Domain
9. Exercise 2.2b reused “Lymphatic System” Public Domain
10. Exercise 2.2b reused “Musculoskeletal System” by OpenStax /
Public Domain
11. Exercise 2.2b reused “Organ Systems” Public Domain
12. Exercise 2.3 reused “Girl Bluepants” by Free SVG / Public
Domain
13. Exercise 3.1 reused “Drop Water Tear” by OpenClipart-Vectors
/ Pixabay License
14. Exercise 3.4 reused “Coffee and Cake Espresso” by AnnaliseArt
/ Pixabay License
15. Exercise 3.4 reused “Cola Cola Soda” by guilaine / Pixabay
License
16. Exercise 3.4 reused “Lightning Bolt” by Clker-Free-Vector-
Images / Pixabay License
17. Exercise 3.4 reused “Japanese Tea Teapot Cup” by
AnnaliseArt / Pixabay License
18. Exercise 4.2 and 5.2a reused “Digestive system without labels”
by Mariana Ruiz / Public Domain
19. Exercise 5.2b reused “Lumen of the Small Intestine” by Allison
Calabrese
20. Exercise 6.1 reused by “Amino Acids” by Allison Calabrese
21. Exercise 7.1 reused “Digestive system without labels” by
1160 | Attributions
22. Exercise 7.2 reused “Red Cross Doctor” by Clker-Free-Vector-
Images / Pixabay License
23. Exercise 7.2 reused “Industrial Safety Signal Symbol” by
DavidRockDesign / Pixabay License
24. Exercise 9.1 reused “Vitamins as Antioxidants” by Allison
Calabrese
25. Exercise 9.1a reused “Digestive system without labels” by
26. Exercise 9.1b reused “Vitamins as Antioxidants” by Allison
Calabrese
27. Exercise 10.2 & 11.3 reused “Milk Carton” by AnnaliseArt /
Pixabay License
28. Exercise 10.2 reused “Carton Drink Juice” by OpenClipart-
Vectors / Pixabay License
29. Exercise 10.2 & 11.3 reused “Swiss Cheese” by OpenClipart-
30. Exercise 10.2 reused “Merchandise Container Plastic” by
BUMIPUTRA / Pixabay License
31. Exercise 10.2 & 11.3 reused “Wheat Yellow Stalk” by Clker-Free-
Vector-Images / Pixabay License
32. Exercise 10.2 & 11.3 reused “Broccoli Bunch Head” by Clker-
Free-Vector-Images / Pixabay License
33. Exercise 10.2 reused “Beat Beet Food Fruit” by OpenClipart-
34. Exercise 10.2 reused “Cabbage Salad Vegetables” by
OpenClipart-Vectors / Pixabay License
35. Exercise 10.2 & 11.3 reused “Pea Garden Fresh” by
simonjozsef / Pixabay License
36. Exercise 10.2 & 11.3 reused “Japanese Food Sushi Beer” by
37. Exercise 10.2 & 11.3 reused “Nuts Peanuts Cashews Plate Of” by
38. Exercise 10.2 reused “Leaf Green Plants” by OpenClipart-
Attributions | 1161
39. Exercise 10.2 & 11.3 reused “Egg Oval Food” by OpenClipart-
40. Exercise 10.2 reused “Salmon Fish Seafood” by OpenClipart-
41. Exercise 10.2 & 11.3 reused “Meat Food Beef” by OpenClipart-
42. Exercise 10.2 & 11.3 reused “Roast Chicken Lunch” by Majdias /
Pixabay License
43. Exercise 10.2 reused “Bananas Fruit Yellow” by OpenClipart-
44. Exercise 10.2 reused “Porcini Mushroom Fungus” by
45. Exercise 10.2 reused “Orange Fruit Healthy” by DryHeartStudio
/ Pixabay License
46. Exercise 10.2 reused “Chicken Fried Wings Food” by
47. Exercise 10.2 reused “French Fries Potato Chips” by
48. Exercise 10.2 & 11.3 reused “Food Eat Salt” by Clker-Free-
49. Exercise 10.2 reused “Bacon Red Pig” by OpenClipart-Vectors /
Pixabay License
50. Exercise 10.2 reused “Chips Food Yummy” by OpenClipart-
51. Exercise 10.2 reused “Noodles Cup Food” by Clker-Free-
52. Exercise 11.3 reused “Cartoon Crab Orange” by OpenClipart-
53. Exercise 11.3 reused “Mollusk Mussel Oyster” by OpenClipart-
Vectors / Pixabay License; “Green Leafy Vegetables” by
OpenClipart-Vectors / Pixabay License; “Oyster Mussel
Mollusk” by OpenClipart-Vectors / Pixabay License
54. Exercise 11.3 & 3.4 reused “Bottledwater Water Bottle” by
StarShopping / Pixabay License
55. Exercise 11.3 reused “Lamb Ribs Meat” by Clker-Free-Vector-
1162 | Attributions
Images / Pixabay License; “Pumpkin Cartoon Orange” by
Clker-Free-Vector-Images / Pixabay License; “Courgette
Zuchinni Curcubit” by Clker-Free-Vector-Images / Pixabay
License; “Egg Hard Boiled Sliced” by Clker-Free-Vector-
Images / Pixabay License “Raisins Box Sweet” by jondometita /
Pixabay License
56. Exercise 12.1 reused “Socio-Ecological Model” by Allison
Calabrese
57. Exercise 12.2 reused “My Plate” by US Department of
Agriculture; “Healthy Eating in the Pacific” by Secretariat of the
Pacific Community (SPC) Guidelines; “Pacific Food Guide” by
Children’s Healthy Living Program
58. Exercise 13.1 reused “Baby” by Marie Kainoa Fialkowski Revilla;
“Birthday Boy Cake” by Kazuend” / Unsplash License
59. Exercise 14.1 reused Brytni K-aloha / CC BY 4.0; “Teenager
Playing American Football” by Riley McCullough / Unsplash
License
60. Exercise 15.1 reused “Smiling Woman” by BBH Singapore /
Unsplash License; “Two Women Riding Bikes” David Marcu/
Unsplash License; “Man wearing blue shirt standing on white
surf board” by Alex Blajan / Unsplash License
61. Exercise 17.2 reused “White check mark in dark green rounded
square”, Emoji from Twitter Emoji project” Twitter, Chris
McKenna / Creative Commons Attribution 4.0 International
62. Exercise 17.2 reused “White x mark in dark red rounded
square”, Emoji from Twitter Emoji project” Twitter, Chris
McKenna / Creative Commons Attribution 4.0 International
63. Exercise 18.1 reused “White Plate” by hrum, Openclipart /
Public Domain
64. Exercise 18.3 reused “Legal Rights Libra Scales” by svgsilh/
Public Domain
Attributions | 1163
Flashcard Images
Note: Most images in the flashcards have been in the flashcards.

Please see the H5P source files for more information. For complex
images, please see below:
1. Beta-Cryptoxanthin reused “Corn” by charlesdeluvio /

Unsplash License; “Lemon” by ohleighann / Unsplash License;
“Pepper” by mukeshsankhyaan / Unsplash License
2. Bioavailability reused “Apple Red Fruit Food Bitten Eaten” by
Clker-Free-Vector-Images / Pixabay License; “Digestive
system without labels” by Mariana Ruiz / Public Domain
3. Carbohydrates reused “Bread” by Jack7 / Public Domain;
reused “The Macronutrients: Carbohydrates, Lipids, Protein,
and Water” by Medicine LibreTexts / Attribution-ShareAlike
4. Fiber reused “Apple Green Fruit” by OpenClipart-Vectors /
Pixabay License; “Beans Legume Food” by JanNijman / Pixabay
License; “Wheat-kernel nutrition” by Jkwchui / CC BY-SA 3.0
5. Fiber reused “Wheat Bran” by Alistair1978 / CC BY-SA 2.5
6. Free Radicals reused “Antioxidants Role” by Allison Calabrese /
Attribution – Sharealike
7. Glucagon reused “Weightlifter Gym Tool Athlete” by
mohamed_hassan / Pixabay License; “Ice Cream Chocolate
Cone Dessert” by Snoy_My / Pixabay License; “Liver Biology
Medical Anatomy” by LJNovaScotia / Pixabay License;
“Pancreas Organ Anatomy” by zachvanstone8 / Pixabay
License
8. Hazard Analysis Critical Control Points reused “HACCP” by
USDAgov / Public Domain; “20120106-OC-AMW-0680” by
USDAgov / Public Domain
9. Hyperlipidemia reused “Osmotic pressure on blood cells
diagram” by Mariana Ruiz / Public Domain
10. Nutrients reused “The Macronutrients: Carbohydrates, Lipids,
Protein, and Water” by Medicine LibreTexts / Attribution-
1164 | Attributions
ShareAlike
11. Organs reused “Pancreas Organ Anatomy” by zachvanstone8 /
Pixabay License; “Liver” by Maritacovarrubias / Public Domain;
“Muscle types” by Bruce Balus / CC BY-SA 4.0
12. Relative Energy Deficiency in Sport reused “Vector Silhouette
of Woman Jogging” by Freesvg/ Public Domain; “Full English
Breakfast” by Freesvg / Public Domain; “Relative Energy
Deficiency in Sport (RED-S) by Alison Calabrese /Attribution –
Sharealike
13. Pasteurization reused “Simple Pasteurization” by Emma /
Attribution-ShareAlike
14. Polychlorated Biphenyls reused in “Polychlorated Biphenyl
structure” by D.328 / Public Domain; “PCBs in power
transformer” by Sturmovik / Attribution-ShareAlike
15. Protein reused “The Macronutrients: Carbohydrates, Lipids,
Protein, and Water” by Medicine LibreTexts / Attribution-
ShareAlike
16. Potential Energy reused “Silhouette Wheel Cyclist Bike” by
mohamed_hassan / Pixabay License
17. Salivary Amylase reused “Salivary glands” by Medicine
LibreTexts / Attribution-ShareAlike
18. Soluble Fiber/Unsoluble Fiber reused “List of High Fiber Foods
and Their Health Benefits” by Urban Wired / Attribution –
Sharealike
19. Solutes reused “Syringe Doctor Needle” by janjf93 / Pixabay
License; “Flask Beaker School Laboratory” by UnboxScience /
Pixabay License
20. Sucrose reused “Figure 03 02 05” by OpenStax Biology / Public
Domain; “Sugar Bag” by Freesvg/ Public Domain
21. Vitamin A reused “Carrot Vegetable Orange Food Cook” by
Ricinator / Pixabay License; “Structure of all-trans retinol” by
NEUROtiker / Public Domain
22. Vitamin C reused “L-Ascorbic acid” by Yikrazuul / Public
Domain; “Tangerines Fruit Clementines” by pixel2013 / Pixabay
License
Attributions | 1165
23. Vitamin D reused “The Functions of Vitamin D” by Allison
Calabrese / Attribution – Sharealike
24. Vitamin K reused “Kale Lacinato Lacinato Kale” by BlackRiv /
Pixabay License; “Phylloquinone structure” by Mysid / Public
Domain
1166 | Attributions

Human Nutrition 2020

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Human Nutrition: 2020 Edition

Human Nutrition: 2020

UNIVERSITY OF HAWAI‘I AT MĀNOA

ALAN TITCHENAL, SKYLAR HARA,

About the Contributors xxvi

Part I. Chapter 1. Basic Concepts in Nutrition

Part II. Chapter 2. The Human Body

Part III. Chapter 3. Water and Electrolytes

Part IV. Chapter 4. Carbohydrates

Part V. Chapter 5. Lipids

Part VI. Chapter 6. Protein

Part VIII. Chapter 8. Energy

Part IX. Chapter 9. Vitamins

Part X. Chapter 10. Major Minerals

Part XI. Chapter 11. Trace Minerals

Part XII. Chapter 12. Nutrition Applications

Part XIII. Chapter 13. Lifespan Nutrition From

Part XIV. Chapter 14. Lifespan Nutrition During

Part XVI. Chapter 16. Performance Nutrition

Part XVII. Chapter 17. Food Safety

Part XIX. Appendices

‘A‘ohe pau ka ‘ike i ka hālau ho‘okahi

This open access textbook was developed as an introductory

This open access textbook was made possible through the

xxvi | About the Contributors

Marie Kainoa Fialkowski Revilla

Marie Kainoa Fialkowski Revilla is a Native Hawaiian faculty

About the Contributors | xxvii

Dr. Titchenal received a PhD in nutrition from the University

xxviii | About the Contributors

Noemi Arceo Caacbay

Noemi Arceo Caacbay is a Masters Student in the Public Health,

About the Contributors | xxix

Allison Calabrese is currently a MS graduate student in the

xxx | About the Contributors

Chynna Chun is an undergraduate student majoring in Tropical

About the Contributors | xxxi

xxxii | About the Contributors

Skylar Hara is an undergraduate student student in the Tropical

About the Contributors | xxxiii

Gemady Langfelder is an undergraduate dietetics student at the

xxxiv | About the Contributors

Ya-Yun is a Graduate Assistant in the Distance Education Program

Christina Gar Lai Young

About the Contributors | xxxv

Ty Lim is an instructional designer who received his MA in

xxxvi | About the Contributors

Billy is the Open Educational Resources Technologist for the

About the Contributors | xxxvii

Kellie is the Distance Education Coordinator for the College of

Dr. Marie Kainoa Fialkowski Revilla

xxxviii | About the Contributors

Please send edits and suggestions directly to Dr. Fialkowski Revilla

About the Contributors | xxxix

This Open Educational Resource textbook has been adapted from:

• Chapter 2 The Human Body

An Introduction to Human Nutrition // CC BY-NC-SA 3.0

• Chapter 1 Basic Concepts in Nutrition

Edited and Reviewed by

Carolyn Donohoe-Mather – University of Hawai’i at Mānoa, Chapter