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20 Learning Outcomes After reading this chapter, you will be able to:

20.1 Distinguish between foodborne infection and foodborne intoxication and provide an example of each.

20.2 Summarize strategies to prevent foodborne illness in the home and when traveling.

20.3 Describe how the food supply is protected in the United States.

20.4 Compare the risks and benefits of food additives and the use of hormones, antibiot- ics, and pesticides in both traditionally and organically grown food.

20.5 Explain what constitutes a sustainable food system.

20.6 Compare the benefits and risks of the use of biotechnology in our current food system.

True or False? 1. Foods that contain pathogens that

cause foodborne illness always smell bad. T/F 2. Handwashing is more effective in

preventing food contamination than using a hand sanitizer. T/F 3. A kitchen sponge is a prime environment for the breeding and spread of bacteria. T/F

4. Freezing foods kills the harmful bacteria. T/F

5. Leftovers that have been stored in the fridge for a week are safe to eat. T/F 6. As long as the expiration date hasn’t passed, packaged food is always safe to eat. T/F 7. Food additives must demonstrate a “zero risk” of cancer to human beings in order to meet FDA approval. T/F

8. A diet consisting only of locally grown foods is a sustainable diet. T/F 9. Foods grown organically that carry the USDA organic seal are free of pesticides. T/F

10. Genetically engineered foods are plentiful in the United States. T/F See page 773–774 for the answers.

Food Safety, Technology, and Sustainability

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What Causes Foodborne Illness? LO 20.1 Distinguish between foodborne infection and foodborne intoxication

and provide an example of each.

Foodborne illness is any disorder caused by consuming contaminated food. It is a major preventable public health threat worldwide. Every year in the United States, 1 in 6 Ameri- cans (or 48 million people) experience foodborne illness, and about 128,000 are hospital- ized.1 Foodborne illness most commonly results in gastrointestinal symptoms such as cramps, diarrhea, and nausea and vomiting, but in extreme circumstances it can result in death. Approximately 3,000 Americans die of foodborne illness every year.2

Pathogens and Their Toxins Cause Most Foodborne Illness The two types of foodborne illness are infection and intoxication. Consuming foods or beverages that are contaminated with disease-causing organisms, known as pathogens, causes foodborne infection. Once ingested, the pathogens multiply in the GI tract and cause illness. Pathogens commonly implicated in foodborne infection include viruses, bacteria, molds, parasites, and prions (Table 20.1).

Eating foods contaminated with a toxin causes foodborne intoxication. Viruses and parasites do not cause foodborne intoxication. Certain species of bacteria, however, do secrete toxins. These include Clostridium botulinum, Staphylococcus aureus, Bacillus cereus, and Escherichia coli. Bacterial foodborne intoxication generally is caused by enterotoxins (entero = intestine, toxin = toxic), which quickly produce gastrointestinal symptoms such as nausea and vomiting—in some cases within 30 minutes of consuming the contami- nated food.3 Some bacteria, such as C. botulinum, secrete neurotoxins (neuro = nerve) that harm the nervous system. Toxins can also accumulate naturally in plants or seafood or result from chemical contamination. These types are discussed later in this chapter. Pathogens may be present in the raw ingredients of the food or may contaminate the food at any stage of the food system. For example, fruit flies have been shown to transfer toxin- producing Escherichia coli O157:H7 to apples under laboratory conditions.4 E. coli as well as several other pathogens are found in the GI tract and fecal matter of humans or animals. Food may become contaminated with these pathogens if it comes into contact with fecal matter, and individuals can become infected by putting food or hands that have been in contact with fecal matter into their mouths. This is a common route of transmission of foodborne illness and is called the fecal-to-oral transmission route.

foodborne illness Sickness caused by consuming pathogen- or toxin-containing food or beverages. Also known as foodborne disease or food poisoning.

pathogens Collective term for disease- causing organisms. Pathogens include microorganisms (viruses, bacteria) and parasites and are the most common source of foodborne illness.

toxin Poison that can be produced by living organisms.

fecal-to-oral transmission Spread of pathogens by putting something in the mouth, such as hands or food, that has been in contact with infected stool.

Have you ever thought about where food comes from before it appears on the supermarket shelf or how safe that food is for you? No matter what you are eating, it likely started out on a farm. Getting food safely from farms to your plate requires several steps and a huge investment of human and natural

resources.

Thanks to monitoring and regulation by the U.S. Food and Drug Administration (FDA), the U.S.

Department of Agriculture (USDA), and other government agencies, consumers in the United States

enjoy a relatively safe food supply. As we explain this chapter, however, foodborne illness continues to

be a threat. Moreover, as the world’s population continues to increase, the pressure to produce more

food with limited natural resources has led to technological changes in the food system that have had

environmental costs, including depletion of natural resources and pollution of air, soil, and water. In

this chapter we discuss the causes of foodborne illnesses and strategies to prevent them. We also explore

techniques of modern food production and their effects on our health and our environment.

food system All processes and infrastructure involved in feeding a population: growing, harvesting, processing, packaging, transporting, marketing, and consuming food.

What Causes Foodborne Illness? 733

Microbe Where You Find It How You Can Get It What You May Experience

Viruses

Norovirus In the stool or vomit of infected individuals

Fecal-to-oral transmission; eating ready-to-eat foods or drinking liquids contaminated by an infected person; eating contaminated shellfish; touch- ing contaminated objects and then putting hands in mouth

Watery diarrhea, nausea and vomit- ing, flulike symptoms; possible fever. Symptoms can appear 24–48 hours after onset, last 24–60 hours, and are typically not serious.

Hepatitis A (HAV) In the stool of infected individuals

Fecal-to-oral transmission; eating raw produce irrigated with contaminated water; eating raw or undercooked foods that have not been properly reheated; drinking contaminated water

Diarrhea, dark urine, jaundice, flulike symptoms that can appear 30 days after incubation and can last 2 weeks to 3 months.

Bacteria

Campylobacter jejuni GI tracts of animals and birds, unpasteurized milk, untreated water, and sewage

Drinking contaminated water or raw milk; eating raw or undercooked meat, poultry, or shellfish

Fever, headache, and muscle pain followed by diarrhea (sometimes bloody), abdominal pain, and nausea; appears 2–5 days after eating; may last 7–10 days; Guillain-Barré syn- drome may occur.

Clostridium botulinum Widely distributed in nature in soil, water, on plants, and in the GI tracts of animals and fish; grows only in environ- ments with little or no oxygen

Eating improperly canned foods, garlic in oil, vacuum-packaged and tightly wrapped food

Bacteria produce a toxin that causes illness by affecting the nervous sys- tem. Symptoms usually appear after 18–36 hours. May experience double vision, droopy eyelids, trouble speak- ing and swallowing, and difficulty breathing. Fatal in 3–10 days if not treated.

Clostridium perfringens

Soil, dust, sewage, and GI tracts of animals and humans; grows only in little or no oxygen

Called “the cafeteria germ” because many outbreaks result from eating food left for long periods in steam tables or at room temperature; bac- teria are destroyed by cooking, but some spores may survive

Bacteria produce toxin that causes illness. Diarrhea and gas pains may appear 8–24 hours after eating; usu- ally last about 1 day, but less severe symptoms may persist for 1–2 weeks.

Escherichia coli O157:H7

GI tracts of some mammals, unpasteurized milk, unchlo- rinated water; one of several strains of E. coli that can cause human illness

Drinking contaminated water, unpas- teurized apple juice or cider, or unpasteurized milk; eating raw or rare ground beef or uncooked fruits and vegetables

Diarrhea or bloody diarrhea, abdomi- nal cramps, nausea, and weakness. Can begin 2 to 5 days after food is eaten, lasting about 8 days.

Small children and older adults may develop hemolytic uremic syndrome (HUS), which causes acute kidney failure. A similar illness, thrombotic thrombocytopenic purpura (TTP), may occur in adults.

Enterotoxigenic Esch- erichia coli (major cause of traveler’s diarrhea)

GI tracts of some mammals and unpasteurized dairy prod- ucts; more common in devel- oping countries

Fecal-to-oral transmission; consum- ing stool-contaminated water and foods from unsanitary water supplies and food establishments

Diarrhea, nausea and vomiting, stom- ach cramping, bloating, fever, and weakness

Listeria monocytogenes

GI tracts of humans and animals, milk, soil, leafy veg- etables; can grow slowly at refrigerator temperatures

Eating ready-to-eat foods such as hot dogs, luncheon meats, cold cuts, fermented or dry sausage, other deli-style meat and poultry, or soft cheeses; drinking unpasteurized milk

Fever, chills, headache, backache, sometimes upset stomach, abdomi- nal pain, and diarrhea; may take up to 3 weeks to become ill; may later develop more serious illness in high- risk individuals

TABLE 20.1 Pathogens That Commonly Cause Foodborne Illness

(continued)

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virus Microscopic organism that carries genetic information for its own replication; can infect a host and cause illness.

host Living plant or animal (including a human) that a microbe infects for the sake of reproducing.

Microbe Where You Find It How You Can Get It What You May Experience

Salmonella (over 2,300 types)

GI tracts and feces of animals; Salmonella enteritidis in eggs

Eating raw or undercooked eggs, poultry, and meat, unpasteurized milk and dairy products, and seafood; can also be spread by infected food handlers

Stomach pain, diarrhea, nausea, chills, fever, and headache usually appear 8–72 hours after eating. May last 1–2 days.

Shigella (over 30 types)

Human GI tract; rarely found in other animals

Fecal-to-oral transmission by con- suming contaminated food and water. Most outbreaks result from eating food, especially salads, prepared and handled by workers with poor per- sonal hygiene

Disease referred to as “shigellosis” or bacillary dysentery. Diarrhea contain- ing blood and mucus, fever, abdomi- nal cramps, chills, and vomiting begin 12–50 hours from ingestion of bacte- ria; can last a few days to 2 weeks.

Staphylococcus aureus

On humans (skin, infected cuts, pimples, noses, and throats)

Consuming foods that were contami- nated by being improperly handled; bacteria multiply rapidly at room temperature

Bacteria produce a toxin that causes illness. Severe nausea, abdominal cramps, vomiting, and diarrhea occur 1–6 hours after eating; recovery within 2–3 days.

Parasites

Cryptosporidium parvum

In the intestines of humans and animals

Fecal-to-oral transmission; drinking contaminated water; eating contami- nated produce

Stomach pains, diarrhea, cramps, fever, and vomiting

Cyclospora cayetanensis

Human stool Fecal-to-oral transmission; drinking contaminated water; eating contami- nated produce

Diarrhea, flatulence, stomach cramps, vomiting, fatigue

Giardia lamblia In the intestines of humans and animals

Fecal-to-oral transmission; drinking contaminated water; eating contami- nated produce

Diarrhea, stomach pains, flatulence

Trichinella spiralis In undercooked or raw meats containing Trichinella worms

Raw or undercooked contaminated meat, usually pork or game meats

Nausea and vomiting, diarrhea, fever, aching joints and muscles

Sources: Data from Centers for Disease Control and Prevention (CDC). 2004. Diagnosis and Management of Foodborne Illness: A Primer for Physicians; CDC. 2012. Norovirus; CDC. 2014. Hepatitis A Information for the Public; CDC. 2006. Traveler’s Diarrhea; Diagnosis and Management of Foodborne Illnesses: A Primer for Physicians. MMWR Recom- mendations and Reports 50 (January 2001):1–69; CDC. 2014. Parasites: Food. All available at www.cdc.gov. USDA Food Safety and Inspection Service. 2013. Foodborne Illness: What Consumers Need to Know. Available at https://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets/foodborne-illness-and- disease/foodborne-illness-what-consumers-need-to-know/CT_Index. Accessed April 2017; USDA Food Safety and Inspection Service. 2015. Parasites and Foodborne Illness. Available at https://www.cdc.gov/parasites/food.html. Accessed April 2017.

TABLE 20.1 Pathogens That Commonly Cause Foodborne Illness (continued)

Eating contaminated food does not always result in foodborne illness. Many patho- gens are killed in the mouth by antimicrobial enzymes and in the stomach by hydrochloric acid. In addition, the potential for a pathogen to cause illness depends on the amount that is consumed, the potency, and the nutritional and immune status of the person who consumes it. Pathogens that survive the natural defense systems of the body undergo an incubation period before the symptoms of illness begin. The delay in the time between when the pathogen is consumed and when it causes illness depends on the type and number of pathogens swallowed and can range from a few hours to a few weeks (refer to Table 20.1).

In the United States the majority of foodborne illness is caused by infection or intoxication from five pathogens: norovirus, Salmonella (bacterium), Clostridium perfringens (bacterium), Campylobacter (bacterium), and Staphylococcus aureus (bacterium that produces a toxin).5 Together these pathogens are estimated to account for 91 percent of all domesti- cally acquired cases of foodborne illness in the United States. The differences between the major pathogen groups are discussed next.

Viruses The term virus denotes a microscopic infectious agent that contains genetic information (DNA or RNA) but must enter a living host, such as a plant or animal cell, to engage in metabolism and reproduction and thus survive. When an individual eats a food that is

What Causes Foodborne Illness? 735

contaminated with a virus, the pathogen can invade the cells of the stomach and intestinal walls. The virus can then cause the cells’ genetic material to start producing more viruses, ultimately leading to illness.6 One virus species—norovirus—is currently responsible for more than half of all foodborne illness in the United States, making it the single most common cause of foodborne disease in this country.7

Bacteria Bacteria are single-celled organisms that lack a nucleus. Thousands of types of bacteria are naturally present in our environment. If you were to swab your kitchen sink right now and look at the results under a microscope, you would find that there are about 16 million bacteria living on each square centimeter (less than half an inch) of the sink. Whereas viruses need a host to survive, bacteria can flourish on both living and nonliving surfaces and can multiply on sponges, dishtowels, cutting boards and countertops, and in sinks. Given the right conditions, a single bacterium can produce colonies of billions of bacteria over the course of just one day.

Not all bacteria cause disease in humans. Recall from Chapter 3 that the GI tract harbors in excess of 1,000 different types of bacteria, many of which are beneficial to health.8 Some produce small amounts of vitamins or enhance GI functioning, whereas others may aid in weight regulation or maintenance of the lining of the GI tract.9 Harm- ful bacteria that enter the GI tract compete for resources with the resident GI flora and, depending on the amount and species of invading bacteria and the condition of the human host, may cause illness.

Contamination of food by certain types of bacteria causes it to spoil; that is, the quality of the food deteriorates. The same bacterial species may or may not introduce pathogens that cause foodborne illness. Though most individuals do not become seriously ill after eating spoiled foods, these items can cause nausea and shouldn’t be eaten. In con- trast to spoiled foods, contaminated foods that contain bacterial pathogens may look and smell perfectly fine. It is not safe to eat food just because it “looks fine” or “smells OK.”

Bacteria may contaminate raw meat, poultry, seafood, eggs, and produce. Lettuce, tomatoes, sprouts, and melons—which are eaten raw—frequently carry pathogenic bac- teria. Although they can grow in just about any food, bacteria grow particularly well on foods high in protein, such as meat, dairy foods, and cooked beans. Even ready-to-eat foods that have been cooked may become contaminated with bacteria from raw products or poor personal hygiene of food handlers.

The foodborne bacterium that causes the largest number of illnesses in the United States is Salmonella. Salmonella is found in the GI tract and feces of animals and in eggs. Most people infected with Salmonella experience diarrhea, fever, and abdominal cramps within 12–72 hours after eating the infected food. The illness usually lasts 4–7 days. People in generally good health before becoming infected usually recover without treatment, but Salmonella infection is the most common cause of foodborne illness that results in hospi- talization and death in the United States.10

One type of foodborne bacterium that is not as common, but is of particular concern, is Escherichia coli O157:H7. Although most strains of E. coli are benign, E. coli O157:H7 secretes a toxin that results in severe, even life-threatening illness for some individuals. E. coli O157:H7 intoxication can cause hemolytic uremic syndrome (hemo = blood, lyti = destroyed, uremic = too much urea in blood), which results in the destruction of red blood cells and damage to and eventual failure of the kidneys.11 Contaminated ground beef has been the culprit behind most cases of foodborne illness caused by E. coli O157:H7. Because bacteria live in the GI tracts of healthy cattle, they can easily come into contact with the meat of the animal during slaughtering and then get mixed in when the beef is being ground. E. coli is destroyed by heat, and most outbreaks occur when people eat undercooked meat, unpasteurized milk, or raw produce contami- nated with the bacterium.

norovirus Most common type of virus that causes foodborne illness; can cause gastroenteritis, or the “stomach flu.”

bacteria Single-celled microorganisms without an organized nucleus. Some are benign or beneficial to humans, whereas others can cause disease.

hemolytic uremic syndrome Rare condition that can be caused by E. coli O157:H7 and results in the destruction of red blood cells and kidney failure. Very young children and older adults are at a higher risk of developing this syndrome.

Viruses, such as the hepatitis A virus, need a host to survive and multiply.

E. coli O157:H7 is a toxin-producing strain of Escherichia coli that can cause severe and even fatal foodborne illness. Most other forms of E. coli are harmless.

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Molds Molds are multicellular fungi that form a filamentous growth and thrive on damp surfaces. Spores give mold the color you see, and when airborne they spread very eas- ily. Some molds cause allergic reactions and respiratory problems. A number of molds grow on foods such as breads, cheeses, and fruits, and not all of them are detrimental; some are used to make certain cheeses like Roquefort, blue, Gorgonzola, and Brie. Molds flourish in foods such as breads made without preservatives because they prefer warmer temperatures and thrive at room temperature. Molds also grow on fruits and vegetables and in the refrigerator on jams, jellies, and even cured, salty meats, given enough time.

Some molds in the right conditions produce mycotoxins that can lead to food intoxi- cation if ingested. One example of this is aflatoxin, a carcinogen sometimes found on moldy peanuts. To avoid mold growth in peanuts and other legumes, store them in a dry environment; avoid eating any legumes that have an off color. Many countries, including the U.S., monitor foods for aflatoxin. Because of their visibility, molds are easy to identify and food that is moldy should be discarded. Cooking and freezing stop mold growth but do not kill the toxins present.12

Parasites Parasites are small organisms, occasionally in the egg or larval phase, that take their nourishment from hosts. They can be found in food and water and are often transmitted through the fecal-to-oral route.13 Foodborne illness caused by parasites is much less com- mon in the United States than is illness caused by other types of pathogens.14

The most common parasitic illness outbreaks in the United States have been caused by just a few types: Cryptosporidium parvum, Cyclospora cayetanensis, Giardia lamblia, and Trichinella spiralis. Both Cryptosporidium parvum and Cyclospora cayetanensis can be found in contaminated water or food sources. Giardia lamblia is one of the most common sources of waterborne illness. Hikers who drink unfiltered water from streams or lakes often become infected with the Giardia parasite. Trichinella spiralis (see photo) is an intestinal worm whose larvae (hatched eggs) can travel from the digestive tract to the muscles of the body. See Table 20.1 for a summary of these parasites and the foodborne illnesses they cause.

Prions A prion is an infectious agent composed of an incorrectly folded protein particle. Pri- ons are responsible for diseases known as spongiform encephalopathies, such as bovine spongiform encephalopathy (BSE, or mad cow disease) in cattle and variant Creutzfeldt- Jakob disease (vCJD) in humans. All known prion diseases affect the structure of neural tissue and are untreatable. Cattle and other ruminant animals develop the disease after consuming feed that contains prion-containing tissues of infected animals. Humans can be infected by consuming the meat or brain tissue of infected livestock.

Great Britain experienced an outbreak of BSE in the 1990s that resulted in vCJD in 150 people. Since that time, the United States has taken specific steps to protect its citizens against beef contaminated with BSE, such as limiting imported meat from coun- tries at risk for BSE and banning ruminant feed containing mammalian protein.15 BSE has not been eradicated, but the incidence of infection is sporadic and rare, and no one is known to have developed vCJD because of eating infected meat in the United States. Since 2003 there have been only four cases of BSE reported in the U.S. cattle supply, the most recent being in 2012.16 In a press briefing, the USDA’s chief veterinary officer said the cow’s meat did not enter the food supply and the carcass was destroyed, so the risk to human health was minimal.17 The World Organization for Animal Health (OIE) recently upgraded the United States’ risk classification for BSE from controlled risk to negligible risk.18

molds Microscopic fungi that live on plant and animal matter; some can produce mycotoxins, which are harmful.

parasites Organisms that live on or in another organism; obtain their nourishment from their hosts.

prion Short for proteinaceous infectious particle; self-reproducing protein particles that cause degenerative brain diseases.

The parasitic roundworm Trichinella spiralis.

What Causes Foodborne Illness? 737

Some Illnesses Are Caused by Natural Toxins Many toxins that occur in plants and animals function as natural pesticides and assist in fending off predators. In many cases, these natural toxins are present in amounts too small to harm humans, but there are instances in which these naturally occurring toxins can make a person seriously ill.

Marine Toxins Cooking fish thoroughly may or may not destroy naturally occurring marine toxins. Eat- ing spoiled finfish, such as tuna and mackerel, can cause scombrotoxic fish poisoning, in which the spoilage bacteria break down proteins in the fish and secrete histamine, a toxin that can accumulate to harmful levels. Consuming fish that contain large amounts of histamine can cause symptoms such as diarrhea, flushing, sweating, and vomiting within 2 minutes to 2 hours.19

Large, predatory reef fish, such as barracuda and grouper, can sometimes be con- taminated with ciguatoxins, which when eaten can cause ciguatera poisoning. In this case, toxins travel through the food chain and bioaccumulate in larger species (see Figure 20.1). Ciguatoxins originate in microscopic sea organisms called dinoflagellates, which are eaten by small tropical fish, which in turn are eaten by larger fish. When people consume the larger fish, the consumption of the accumulated concentrations of toxin can result in illness.20 In addition to experiencing various gastrointestinal discomforts, individuals infected with ciguatera may have temperature sensation reversal in their mouth when they eat.21 For example, hot liquids and hot foods feel cold, and vice versa.

Marine neurotoxins can contaminate certain shellfish, such as mussels, clams, scal- lops, oysters, crabs, and lobsters, that typically live in the coastal waters of New England and the Pacific states. Neurotoxins are also produced by a particular reddish-brown- colored dinoflagellate. These reddish-brown dinoflagellates can become so abundant that the ocean appears to have red streaks, also known as red tides. Eating shellfish contami- nated with neurotoxins can lead to paralytic shellfish poisoning. Symptoms include mild numbness or tingling in the face, arms, and legs, as well as headaches and dizziness. In severe cases muscle paralysis, the inability to breathe, and death could result.22

Toxins in Other Foods Many plant foods naturally contain toxins in small amounts and don’t generally pres- ent problems when eaten in reasonable portions; however, consuming them in large amounts could be harmful. For example, potatoes that have been exposed to light can

marine toxins Chemicals that occur naturally and contaminate some fish.

scombrotoxic fish poisoning Condition caused by consuming spoiled fish that contain large amounts of histamines; also referred to as histamine fish poisoning.

ciguatera poisoning Condition caused by marine toxins that are produced by dinoflagellates and have bioaccumulated in fish that the affected person consumes.

bioaccumulate To build up the levels of a substance or chemical in an organism over time, so that the concentration of the chemical is higher than would be found naturally in the environment.

paralytic shellfish poisoning Condition caused by a reddish-brown-colored dinoflagellate that contains neurotoxins.

▲ Figure 20.1 Bioaccumulation of Toxins

Dinoflagellates produce toxin and/or other microscopic organisms become contaminated with toxins.

Level 1 Small fish eat the dinoflagellates. Over time, the toxins accumulate and become more concentrated in their bodies.

Level 2 Large, predatory fish consume the smaller contaminated fish, which increases their toxin concentration.

Level 3 Fishermen catch the larger fish for human consumption.

Level 4

Increasing accumulation of biotoxins equals bioaccumulation

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develop a green tinge on the surface, which indicates that they contain increased amounts of solanine, a toxin that can cause fever, diarrhea, paralysis, and shock. Peeling pota- toes and removing the green layer ensures that the potato can be safely eaten. Eating 2–5  milligrams of solanine per kilogram of body weight results in symptoms and eat- ing 3–6 milligrams of solanine per kilogram of body weight may result in death.23 The amount of solanine in potatoes is very small, on the order of about 0.2 milligrams per gram of potato. Eating approximately 1 pound of green potatoes would likely make a 100-pound person ill.

However, other foods contain toxins that are harmful even in trace amounts, and so should be avoided altogether. Certain wild mushrooms, for example, are poisonous; they contain toxins that can cause nausea and vomiting, liver damage, and death.

Chemical Agents Sometimes Cause Foodborne Illness Consumers are becoming increasingly concerned about environmental damage caused by industrial and household chemicals. Traces of these substances can travel through the food chain and be ingested by people, posing numerous risks to health. Awareness of the potential environmental and health risks caused by these chemicals has led to a search for safer alternatives.

Polychlorinated Biphenyls Polychlorinated biphenyls (PCBs) are industrial pollutants that occur in the food sup- ply. These chemicals were used as coolants and insulating fluids for transformers and capacitors, as flame-retardants, and in the manufacture of plasticizers, waxes, and paper. Production of PCBs was banned in 1979 due to their high toxicity and persistence— resistance to being broken down—in the environment.24

PCB exposure in adults can cause skin conditions such as acne and rashes as well as liver damage. It is of particular concern for pregnant and lactating women because prenatal exposure and consumption of contaminated breast milk can damage a child’s nervous system and cause learning defects. Also, because young children are smaller, exposure to PCBs has a proportionately greater effect on them than would the same level of exposure in adults. Moreover, exposure to PCBs can cause cancer in animals and may be carcinogenic in humans.25

Although PCBs are no longer manufactured in the United States, they do not degrade and can therefore still make their way into the environment through releases from hazard- ous waste sites, the burning of commercial or municipal waste, and the improper disposal of consumer products, such as old television sets and electrical fixtures and devices.26 PCBs in the air eventually return to our land and water by runoff in snow and rain and may bioaccumulate in larger predatory fish that live in polluted waters (see Figure 20.1).27

The EPA began regulating PCBs in drinking water in 1992, and the agency is work- ing to lower the amount of PCBs in the environment.28 Although the FDA routinely monitors PCB levels in the food supply, the toxin can be found in nonregulated food sources, such as locally caught fish. Consumers should therefore research and adhere to local fish consumption advisories. See the Table Tips for the EPA website that lists cur- rent advisories, as well as tips to minimize exposure to toxins and chemical agents in fish and seafood.

Methylmercury Mercury occurs naturally, but is also produced as an industrial by-product or pollutant. An airborne form of mercury can accumulate on the surface of streams and oceans and be transformed by the bacteria in the water into the toxic form of methylmercury. Meth- ylmercury toxicity is associated with nervous system damage in adults and impaired neu- rological development in infants and children.29 Methylmercury may bioaccumulate in

solanine Toxin found in potato surfaces exposed to light that can cause fever, diarrhea, and shock if consumed in large amounts.

polychlorinated biphenyls (PCBs) Synthetic chemicals that have been shown to cause cancer and other adverse effects on the immune, reproductive, nervous, and endocrine systems in animals; may cause cancer in humans.

TABLE TIPS

Avoid Toxins and Chemical Agents in Seafood

Keep fish, especially finfish—such as fresh tuna, mackerel, grouper, and mahi mahi—chilled in the refrigerator to prevent spoilage and the formation of histamine toxins.

Never consume finfish or shellfish that is sold as bait, as these do not meet food safety regulations.

Observe all fish consumption advisories. To learn if an advisory is in place for the fish in your area, search for “Fish Consumption Advisories” at www.epa.gov.

If you fish recreationally, always check with the local or state health department for specific advice based on the local waters to avoid eating PCB-containing fish.

Eat a variety of types of fish to minimize the exposure to a particular toxin.

Source: Adapted from Centers for Disease Control and Prevention. 2016. Harmful Algal Bloom (HAB)-Associated Illness. Available at https://www.cdc.gov/habs/illness-symptoms- marine.html; Agency for Toxic Substances and Disease Registry. Updated 2014. ToxFAQ for Polychlorinated Biphenyls (PCBs). Available at https://www.atsdr.cdc.gov/toxfaqs/ tf.asp?id=140&tid=26.

What Strategies Can Prevent Foodborne Illness? 739

fish, seafood, and other wildlife and cause toxicity to humans if consumed in sufficient quantities. Larger fish—including shark, swordfish, king mackerel, and tilefish—contain high levels of mercury, so the FDA and EPA recommend that women who are or may become pregnant, women who are nursing, and young children should avoid consuming these fish.30

Some People Are at Higher Risk for Foodborne Illness Older adults, young children, pregnant women, and people with certain disorders have compromised immunity. They are therefore more susceptible to contracting foodborne illness and suffering complications than the rest of the population.

Age-related deterioration of the immune system increases the risk for foodborne ill- ness. In addition, because the level of acidic gastric juice produced by the stomach declines with age, fewer foodborne pathogens are destroyed in the stomach. This puts older adults at higher risk of serious disease and death from foodborne illness.31 As the percentage of Americans 65 years of age and older increases—it is projected to reach 21.7 percent by the year 2040—more Americans will be at higher risk for severe foodborne illness.32

In addition to age, any condition that weakens a person’s immune system, such as HIV, AIDS, cancer, or diabetes, can increase the risk of serious foodborne illness.33 Also, the hormonal shifts that occur during pregnancy can weaken a pregnant woman’s immune system, making her more vulnerable to a potentially life-threatening illness caused by the bacterium Listeria monocytogenes. (See Spotlight: The Lowdown on Listeria.)

Individuals in institutional settings (such as nursing homes, hospitals, schools, and on cruise ships), where groups of people eat foods from the same source, are also at higher risk of foodborne illness. Improper food handling and poor hygiene practices of foodser- vice workers are often the causes of foodborne disease outbreaks in institutional settings.

LO 20.1: THE TAKE-HOME MESSAGE Foodborne illness is a serious public health problem. Consuming pathogens in contaminated food or drinks causes foodborne infection, whereas consuming toxins causes foodborne intoxica- tion. Viruses and bacteria are the most common causes of foodborne infection in the United States, although parasites and prions can also cause foodborne illness. Toxins can be released into foods by bacteria or can occur naturally in foods such as mushrooms or as the result of bioaccumulation of industrial chemicals such as polychlorinated biphenyls (PCBs) and methylmercury. Cer- tain populations, including older adults, children, pregnant women, and those with compromised immune systems, are at higher risk of contracting foodborne illness and suffering complications.

What Strategies Can Prevent Foodborne Illness? LO 20.2 Summarize strategies to prevent foodborne illness in the home and

when traveling.

One of the best ways to prevent foodborne illness is to keep the pathogens that cause it from flourishing in foods. For example, in order for bacteria to thrive and multiply, they must have the proper conditions. These include (1) a source of nutrients (including glucose, amino acids, or vitamins and/or minerals), (2) moisture, (3) a pH above 4.6 (con- sidered low acidity), (4) temperatures in the range of 40–140°F (4.4–60°C), and (5) time (at least 20 minutes) to multiply.34 Protein- and nutrient-rich animal-based foods, such as

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The Lowdown on ListeriaSPOTLIGHT

Listeriosis, the illness caused by the bacterium Listeria monocytogenes, seriously affects approximately 1,600 individuals in the United Sates annually, with pregnant women being 10 times more likely than other people to become infected.1 Listeria can reach the fetus through the placenta, be trans- mitted to the developing fetus, and lead to severe illness, premature birth, mis- carriage, and stillbirth. Older adults and those with a weakened immune system are also at risk for becoming very sick or even dying.

Animals can harbor Listeria, which leads to contamination of meat and dairy foods. Pasteurization kills Listeria, so unpasteurized soft cheeses, such as Camembert, Brie, and blue cheeses, carry a higher risk of contamination. Compared with hard cheeses such as Parmesan, these soft cheeses are less acidic and contain more moisture, two conditions that enhance bacte- rial growth. Even though cooking can also destroy Listeria, the lower cooking temperature used during the process- ing of soft cheeses isn’t high enough to destroy this bacterium. Because contamination can also occur after processing, many outbreaks have been associated with other foods such as hot dogs, deli-style luncheon meats, salami, and paté. Listeria can also

continue to multiply at refrigerated temperatures.

The following tips can help pregnant women and other higher-risk individu- als reduce their likelihood of contracting Listeria:2,3

• Heat ready-to-eat luncheon meats, cold cuts, fermented and dry sausage, deli-style meat and poultry products, and hot dogs until they are steamy hot to kill any existing bacteria before serving.

• Wash your hands with hot, soapy water after touching these types of ready-to-eat foods, or any foods for that matter. Also thoroughly wash cut- ting boards, dishes, and utensils.

• Avoid soft cheeses such as feta, Brie, Camembert, blue-veined (blue) cheese, and Mexican-style cheeses unless they are made with pasteurized

milk. (Read the ingredients list to see if pasteurized milk was used.) You can safely eat hard cheeses, semi-soft cheese such as mozzarella, pasteur- ized processed cheeses, cream cheese, and cottage cheese.

• Avoid unpasteurized milk and foods made from unpasteurized milk.

• Avoid refrigerated smoked seafood such as smoked salmon (lox or nova style), trout, whitefish, cod, tuna, or mackerel unless they are used in an entrée such as a heated casserole. You can safely eat canned fish and shelf-stable smoked seafood.

• Avoid refrigerated paté or meat spreads. You can safely eat canned or shelf-stable varieties.

• Eat precooked or ready-to-eat perishable items before the expiration date on the food label.

References 1. Centers for Disease Control and Prevention.

2016. Listeria (Listeriosis). Available at www.cdc.gov/listeria. Accessed April 2017.

2. Ibid. 3. USDA. 2016. Fact Sheets: Protect Your Baby and

Yourself from Listeriosis. Available at https:// www.fsis.usda.gov/wps/portal/fsis/top- ics/food-safety-education/get-answers/ food-safety-fact-sheets/foodborne-illness- and-disease/protect-your-baby-and-yourself- from-listeriosis/CT_Index. Accessed April 2017.

Unpasteurized soft cheese can be contami- nated with Listeria.

raw and undercooked meat, poultry, seafood, eggs, and unpasteurized milk, are the most common types of foods that provide conditions for rapid bacterial growth.

Bacteria thrive in moist environments, such as in raw chicken that is sitting in its juices. Dry foods, such as uncooked rice, sugar, flour, and cereals, do not usually support bacterial growth until they are hydrated with a liquid. However, infected utensils or hands can contaminate these foods. For example, a person with infected hands who takes a handful of cereal directly out of the box transfers bacteria onto the cereal. Although the bacteria may not multiply, they survive and, once eaten, will grow in the moist environ- ment of the GI tract, possibly resulting in foodborne illness.

Bacteria don’t thrive in acidic foods (pH less than 4.6) such as vinegar and citrus fruits, so these foods seldom provide the conditions necessary for growth. However, animal-based foods have a higher pH and provide the right conditions for bacteria to flourish.

Bacteria multiply most abundantly between the temperatures of about 40°F and 140°F. At body temperature, or 98.6°F (37°C), bacteria can divide and double within

What Strategies Can Prevent Foodborne Illness? 741

20 minutes and multiply to millions in about 12 hours.35 Because bacteria need such a short time period to multiply, it is important to realize that perishable food, such as raw meat, left at room temperature for an extended period can become a feast for bacterial growth.

Consumers can take various measures when consuming and handling food to reduce the risk of foodborne illness. These include preventing the growth of bacteria and destroy- ing any pathogens that may be present. This can be done through the consistent practice of proper food consumption, handling, and storage strategies at home and while traveling.

Practice Food Safety at Home An easy way to remember the important points of home food safety is by focusing on the “Core Four” of the Fight BAC! campaign of the nonprofit Partnership for Food Safety Education: Cleaning, Combating cross-contamination (or separating), Cooking, and Chilling (Figure 20.2).36

Clean Hands and Produce Cleaning is one of the simplest ways to reduce the chances of microbial contamination, and proper handwashing is one of the most important overall strategies for preventing foodborne illness. If everyone practiced proper handwashing techniques, the incidences of foodborne illness could decrease by about half.37 The Table Tips summarize proper handwashing techniques.

Proper handwashing refers to washing hands thoroughly, as well as washing hands regularly. This last part, regular washing, is where many people fall short. Germs accumu- late on hands from a variety of sources throughout the day, and if hands are not regularly washed, these germs can infect the body after being passed into the mouth, nose, and eyes. Individuals also spread the germs to others by touching surfaces such as doorknobs.38

In instances where handwashing is not an option, such as when traveling or eating on the run, using disposable wipes or hand gel sanitizers can be an excellent

TABLE TIPS

Wash Your Hands!

After using the toilet

After changing a diaper

After touching animals

Before and after food preparation, especially when handling raw meat or poultry

After blowing your nose

After coughing or sneezing into your hands

Before and after treating wounds

After handling garbage

Before inserting or removing contact lenses

Proper handwashing:

Wet hands with warm, running water and apply liquid soap or use clean bar soap. Lather well.

Rub hands together vigorously for at least 20 seconds (recite the alphabet twice or sing “Happy Birthday” twice).

Scrub all surfaces, including the backs of hands, wrists, between fingers, and under fingernails.

Rinse well.

Dry hands with a clean cloth towel or disposable towel.

Use a towel to turn off the faucet and, if in a public restroom, use a clean towel to open the door as well.

Source: Adapted from Mayo Clinic. 2016. Hand Washing: Do’s and Don’ts. Available at www.mayoclinic.org/healthy-lifestyle/adult- health/in-depth/hand-washing/art-20046253. Accessed April 2017.

▲ Figure 20.2 Fight BAC! The Fight BAC!® symbol sums up the “Core Four” of keeping food safe in the kitchen: clean, combat cross-contamination (separate meats from ready-to-eat foods), cook thoroughly, and chill to a cold enough temperature. Source: www.fightbac.org/food-safety-basics/the-core-four-practices/

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alternative. Only the alcohol-based products are effective in killing germs. The Centers for Disease Control and Prevention (CDC) recommends choosing products that contain at least 60 percent alcohol.39 Individuals should keep hand sanitizers in the car, purse, desk drawer, and backpack so that proper hand hygiene can be practiced at all times.40

In addition to hands, anything that touches food, such as knives, utensils, and coun- tertops, should be thoroughly cleaned between each use. Cutting boards should be placed in the dishwasher or scrubbed with hot, soapy water and rinsed after each use. Nonporous cutting boards made of plastic, marble, and tempered glass are easier to keep clean than the more porous wooden cutting boards or wooden surfaces. Cracked cutting boards should be discarded, as they can harbor pathogenic microbes. Kitchen sinks and cutting boards should be regularly sanitized by filling the sink with hot water and adding one teaspoon of bleach per quart of water. Let the board sit in the sanitizing liquid for a few minutes to kill the microbes, then rinse it thoroughly.

A kitchen sponge is an ideal environment for bacteria because it provides the ideal temperature, moisture, and nutrients (food particles). Household kitchen sponges and dishcloths have been shown to harbor more bacteria than toilet seats.41 Consequently, sponges and dishcloths need to be replaced often and between replacements washed after each use in the hot cycle of the washing machine, preferably with bleach in addition to soap. They can also be soaked in a bleach solution along with the cutting boards, run through the dishwasher (including the dry cycle), or placed in the microwave for 1 minute at its highest setting.42 To avoid fire hazards, be sure to use the microwave method only with damp sponges and those without metal.

All fruits and vegetables should be thoroughly washed under running tap water before eating. Even foods like cantaloupe, which doesn’t have an edible peel or rind, have been known to carry Salmonella and E. coli, and the microbe can be transferred from the peel or rind to the fruit by the knife used to cut it open. Washing firm fruit with a vegetable brush helps remove any dirt or microbes on its surface. Fruit should be cut only on a clean cutting board. Washing fruits and vegetables offers the additional advantage of removing most of the pesticide residue that may be present. Pesticides are discussed in more detail later in this chapter.

Combat Cross-Contamination Cross-contamination is the spread of microbes from one item to another. It can occur, for example, when washed lettuce—which is going to be eaten raw—comes into contact with raw meat, poultry, or fish during food preparation. To avoid cross-contamination between animal-based foods and fresh bread or raw fruits and vegetables, maintain sepa- rate cutting boards for meat and nonmeat foods. If you have just one cutting board, wash it thoroughly in hot, soapy water immediately after use.

Also, when grocery shopping, raw meats, fish, and poultry should be bagged sepa- rately from produce. Once home, these foods should either be frozen or stored in airtight containers on the bottom shelf of the refrigerator. This prevents contaminated drippings from coming in contact with cooked foods or raw fruits and vegetables. Marinades that are used to tenderize and flavor raw meats, poultry, or fish should never be reused as a basting or serving sauce. All plates and bowls that have contained raw meats, poultry, and fish should be thoroughly washed before reuse. For example, at a barbecue, the plate that held the raw hamburgers should never be used to serve the cooked burgers unless it has been thoroughly washed.

Another common source of cross-contamination occurs when soiled dishtowels are used to dry clean hands, dishes, or utensils. A towel that was used to wipe up raw meat juices or your hands can transfer those microbes to your clean dishes or utensils. You could easily coat those clean surfaces with a layer of germs. Figure 20.3 summarizes some of the ways to combat cross-contamination in the kitchen.

cross-contaminate Transfer of pathogens from a food, utensil, cutting board, kitchen surface, and/or hands to another food or object.

The countertop sponge may very well be the most contaminated item in your kitchen. Food scraps, moisture, and room temperature can lead to a thriving bacterial colony on this common cleaning item.

What Strategies Can Prevent Foodborne Illness? 743

Cook Foods Thoroughly A common food safety misconception is that meat that looks brown is fully cooked. Look at the two hamburger patties in Figure 20.4. The brown patty on the bottom might look more thoroughly cooked than the pinker patty above, but it’s not. The color of beef is largely determined by myoglobin, the iron-containing protein that provides the purplish-red pigment in meat (and in human muscle tissue). The denaturing of this protein is what causes meat to turn from pink to brown during cooking. However, if the meat starts out brown, this color change won’t occur. Thus, a burger could look “done” when it may still be raw in places. Research has shown that hamburgers can look “well done” while only having reached an internal temperature of approximately 135°F (57.2°C).43 Ground meat (beef, pork, veal, and lamb) must reach an internal tempera- ture of 160°F (71.1°C) to kill pathogens known to cause illness. In contrast, some lean or treated varieties of beef can remain pink even though they have reached an internal temperature of 160°F.

Poultry color can also be misleading because it can remain pink after thorough cook- ing. This is caused by a chemical reaction that occurs in the poultry from gases in the oven that give the meat a pink tinge. Because younger birds have thin skins, the gases can react with their flesh more easily and make the meat look pinker than that of older birds. Also, nitrates and nitrites added to some poultry as a preservative can give poultry a pink tinge (see the discussion of food additives later in the chapter).44

The only way to determine if food has reached an internal temperature high enough to kill pathogens is to use a food thermometer. Figure 20.5 shows several types of food thermometers available for use when cooking. Table 20.2 provides a list of the internal temperatures that foods should reach to ensure that they are safe to eat.

myoglobin Protein that provides the purplish- red color in meat and poultry.

Do store raw meats separate from and ideally below produce and cooked foods.

Don’t reuse the marinade unless it has been boiled.

Don’t use dirty towels to dry clean dishes.

Do discard worn cutting boards with lots of cuts and scratches.

Do wash utensils, countertops, and cutting boards thoroughly with hot soapy water after they touch raw meat, fish, or poultry.

Do sanitize sponges and cutting boards with chlorine bleach solution.

Do use separate designated cutting boards for meats and vegetables.

Do marinate raw meat in the refrigerator in sealed containers.

▲ Figure 20.3 The Do’s and Don’ts of Avoiding Cross-Contamination

▲ Figure 20.4 Cook Meats Thoroughly to Kill Pathogens A hamburger needs to reach an internal tem- perature of 160°F to ensure that all foodborne pathogens are killed. Color is not an indication of “doneness.”

a

b Cooked to internal temperature of 135°F

Cooked to internal temperature of 160°F

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▲ Figure 20.5 Food Thermometers There are several types of food thermometers available for measuring the internal temperature of cooked foods. The thermometer should be inserted at least one-half-inch deep into the food and should be washed thoroughly after each use and before insertion into any food.

Thermometer fork combination thermometers allow you to stab and check. A device that measures the temperature in the food is located in the tines of the fork.

Thermocouple digital food thermometer displays the temperature of the food within 6 seconds after placement.

Thermistor digital food thermometers take approximately 10 seconds to display the temperature of the food on the dial.

Oven-safe bimetallic-coil thermometers are most useful when cooking thick foods such as roasts and turkeys. They are unique, as they can stay in the food during cooking.

If You Are Cooking This Food

The Food Thermometer Should Reach (°F)*

Ground Meat and Meat Mixtures

Beef, pork, veal, lamb

160

Turkey, chicken 165

Fresh Beef, Veal, Lamb

145**

Poultry

Chicken, turkey, whole or parts

165

Duck and goose 165

Fresh Pork

Ham, raw 145**

Ham, precooked (to reheat)

140

Fish and Shellfish 145

Eggs and Egg Dishes

Eggs Cook until yolk and white are firm

Egg dishes 160

Leftovers and Casseroles

165

*The thermometer should be placed in the thickest part of the food item. **Meat should rest for 3 minutes before consumption to ensure that pathogens are destroyed.

Sources: Adapted from USDA Food Safety and Inspection Service. 2015. Kitchen Thermometers. Available at https://www.fsis.usda.gov/wps/portal/ fsis/topics/food-safety-education/get-answers/food- safety-fact-sheets/appliances-and-thermometers/ kitchen-thermometers/ct_index. Accessed April 2017; USDA Food Safety and Inspection Service. 2016. Keep Food Safe! Food Safety Basics. Available at https://www.fsis.usda.gov/wps/portal/fsis/topics/food- safety-education/get-answers/food-safety-fact-sheets/ safe-food-handling/keep-food-safe-food-safety- basics/ct_index. Accessed April 2017.

TABLE 20.2 Safe Food Temperatures

Chill Foods at a Low Enough Temperature Proper chilling and refrigeration of foods is essential to inhibit the growth of pathogens. But just how low must the temperature be? Foodborne bacteria multiply most rapidly in temperatures between 40° and 140°F (or 4.4–60°C), a range known as the “danger zone.” To keep foods out of the danger zone, hot foods must be kept hot, above 140°F, and cold foods kept cold, below 40°F, or even lower (see Figure 20.6). This means that when cooked foods like lasagna are on a buffet table, they should be sitting on a hot plate or other heat source that keeps their temperature above 140°F, while cold prepared foods such as potato salad should be kept at 40°F or below at all times.45

Refrigerating foods for storage is another key aspect of keeping them chilled and inhibiting the growth and reproduction of pathogenic microbes. With the exception of the Listeria bacterium, cold temperatures slow down microbes’ ability to multiply to dangerous levels; note that chilling does not kill them or completely stop their growth. To ensure that the growth of microbes on foods is controlled, refrigerator temperatures should be set at or below 40°F (4.4°C). The temperature for the freezer should be set at 0°F (-17.7°C) or below. Food stays safe in the freezer indefinitely, though its quality may deteriorate. “Freezer burn” may occur if frozen food is not tightly wrapped and gets exposed to air. Freezer burn causes the texture of food to change, as it dries out and accumulates ice crystals. This results in a less pleasant taste and appearance, but it isn’t harmful. Most microbes become dormant and are unable to multiply when they are frozen, but they aren’t destroyed. When food is defrosted the microbes can multiply again under the right conditions.

Two hours is the critical time to remember. Perishables such as raw meat and poultry left out at room temperature (a temperature within the danger zone) for more than 2 hours may not be safe to eat. In temperatures above 90°F (32.2°C), such as in the kitchen in the summertime, foods shouldn’t be left out at room temperature for more than 1 hour.46 Leftovers should be refrigerated within 2 hours of being prepared. Large roasts and pots of soup or stews should be divided into smaller batches and placed in shallow containers in order to cool more quickly in the refrigerator. If these items have been left in the danger zone for too long, bacteria can grow and may also produce toxins that are heat resistant.

danger zone Range of temperatures between 40° and 140°F at which foodborne bacteria multiply most rapidly; room temperature falls within the danger zone.

What Strategies Can Prevent Foodborne Illness? 745

These toxins are not destroyed even if the food is cooked to a proper internal temperature and could cause illness if consumed.47

Once food is refrigerated it shouldn’t be held for more than a few days, even when kept at the proper temperature. A good rule of thumb is that leftovers can be in the refrig- erator at 40°F or below for no more than 4 days. Remember, after 4 days in the refrigera- tor, leftovers are ready for disposal. Raw meats, poultry, and seafood can be safely kept in the refrigerator for a maximum of 2 days. A good food safety strategy is the acronym FIFO, which means “first in, first out.” In other words, use food that has been in the refrigerator the longest first. Table 20.3 lists the storage times for various foods. Don’t eat food that you suspect may not be safe. If you are unsure about the safety of a food, remember this rhyme: When in doubt, throw it out.

Minimizing the risk for developing a foodborne illness requires a conscious effort to clean, avoid cross-contamination, cook, and chill to keep foods safe. Think about how many of these strategies you use in your own kitchen and use the Self-Assessment to help identify areas in which you may need to improve your food safety habits.

▲ Figure 20.6 The Danger Zone Bacteria multiply rapidly in the “danger zone,” between temperatures of 40° and 140°F.

0°

40°

68°

170°

160°

145°

140°

165°

Well-done meats

Medium-done meats, raw eggs, egg dishes, pork, ground meats Medium-rare beef steaks, roasts, veal, lamb

Stuffing, poultry, reheated leftovers

Safe zone (above

140°)

Hold hot foods

Do not keep foods between 40°F and 140°F for more than 2 hours or for more than 1 hour when the air temperature is greater than 90°F

Room temperature

Refrigerator temperatures

Freezer temperatures

Safe zone (below 40°F)

Te m

pe ra

tu re

(F ah

re nh

ei t)

Danger zone

Product Storage Time after Purchase*

For Raw Foods

Poultry 1 or 2 days

Beef, veal, pork, and lamb 3–5 days

Ground meat and ground poultry 1 or 2 days

Fresh variety meats (liver, tongue, brain, kidneys, heart, intestines)

1 or 2 days

Cured ham, cook-before-eating 5–7 days

Sausage from pork, beef, or turkey, uncooked 1 or 2 days

Fish 1 or 2 days

Eggs 3–5 weeks

Unopened, after Purchase*

After Opening*

For Processed Product Sealed at Plant

Cooked poultry 3–4 days 3–4 days

Cooked sausage 3–4 days 3–4 days

Sausage, hard/dry, shelf-stable 6 weeks/pantry 3 weeks

Corned beef, uncooked, in pouch with pickling juices

5–7 days 3–4 days

Vacuum-packed dinners, commercial brand with USDA seal

2 weeks 3–4 days

Bacon 2 weeks 1 week

Hot dogs 2 weeks 1 week

Luncheon meat 2 weeks 3–5 days

Ham, fully cooked, whole 7 days 3 days

Ham, canned, labeled “keep refrigerated” 9 months 3–4 days

Ham, canned, shelf-stable 2 years/pantry 3–5 days

Canned meat and poultry, shelf-stable 2–5 years/ pantry

3–4 days

Leftovers 3–4 days

*Based on refrigerator home storage (at 41°F [5°C] or below) unless otherwise stated. Source: Adapted from USDA Food Safety and Inspection Service. 2016. Keep Foods Safe! Food Safety Basics. Available at https://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact- sheets/safe-food-handling/keep-food-safe-food-safety-basics/ct_index. Accessed April 2017.

TABLE 20.3 Safe Storage of Perishable Foods

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Practice Food Safety While Traveling Travelers should follow food safety procedures to reduce the risk of illness while trav- eling abroad. Each year, up to 50 percent of international travelers are estimated to have their trips interrupted by foodborne illness.48 One type of E. coli, enterotoxi- genic (entero = intestines, toxi = toxin, genic = forming) E. coli, is a common cause of traveler’s diarrhea. Traveler’s diarrhea causes watery diarrhea and gastrointestinal cramps and is primarily caused by consuming contaminated food, water, or ice. People visiting countries where sanitation is poor, including some developing countries in Latin America, Africa, the Middle East, and Asia, are at a higher risk of contracting it.49 See the Table Tips for suggestions on how to avoid traveler’s diarrhea and other forms of foodborne disease while traveling.

traveler’s diarrhea Common pathogen- induced intestinal disorder experienced by some travelers who visit areas with unsanitary conditions.

TABLE TIPS

Avoiding Foodborne Illness While Traveling

If you are traveling abroad, look up the country you’re visiting on the Centers for Disease Control’s National Center for Infectious Diseases Travelers’ Health Destination website at www.cdc.gov/ travel/destinat.htm to find out about any specific health advisories for that area.

Do not eat raw or undercooked meat or seafood.

Do not consume raw fruits and veg- etables unless you wash and peel them. Thoroughly cooked fruits and vegetables should be safe to eat.

Do not consume foods from street vendors or other vendors who appear to leave food at room temperature for extended periods of time.

Do not consume food or beverages from vendors who appear unclean or have unclean establishments. A clean environment is no guarantee against foodborne illness, but unclean environ- ments are more likely to spread food- borne illness.

Do not drink tap water or use ice made from tap water unless it has been boiled first or treated with iodine or chlorine. Bottled water should be safe.

Do not consume unpasteurized milk or other unpasteurized dairy foods.

Source: Adapted from Centers for Disease Control and Prevention, Division of Bacte- rial and Mycotic Diseases. 2013. Travelers’ Diarrhea. Available at https://wwwnc.cdc.gov/ travel/page/travelers-diarrhea. Accessed April 2017.

Self-Assessment

How Do Your Food Safety Habits Stack Up? Take the following quiz to find out.

How Often Do You Always Sometimes Never

Wash your hands before preparing food?

Scrub your fruits and vegetables under cold, running water before eating them?

Use an insulated pouch with an ice pack to carry your perishable lunches and snacks, such as meat- filled sandwiches and/or yogurt and cheese?

Wash your hands after using the bathroom?

Throw out refrigerated leftovers after 4 days?

Chop raw vegetables on a clean chopping board rather than the one you just used for raw meat, fish, or poultry?

Use a thermometer to determine if the meat or poul- try you are cooking is done?

Answer If you answered “Always” to all of the above you are practicing superior food safety skills. If you didn’t, there’s more you can do to reduce your chances of contracting a foodborne illness.

LO 20.2: THE TAKE-HOME MESSAGE Proper food handling and storage strategies—particularly cleaning, preventing cross-contamination, cooking to recommended temperatures—and chilling at recommended temperatures, can help reduce the risk of foodborne illness. Anything that comes in contact with foods, including hands, should be thoroughly washed, and produce should always be washed before eating it. Fresh bread, fruits, and vegetables need to be kept separate from raw meats, poultry, and fish and from any utensils that touch them. Checking the internal temperature of cooked food with a food ther- mometer is the only accurate way to tell if it is safe to eat. Perishables should be properly and promptly chilled to minimize the growth of bacteria. Raw meat, poultry, and seafood should be used within 2 days. Leftovers that are refriger- ated should be discarded after 4 days. Extra caution is needed when traveling abroad to avoid foodborne illness.

How Is the Food Supply Protected? 747

How Is the Food Supply Protected? LO 20.3 Describe how the food supply is protected in the United States.

The food system includes the techniques and resources involved in growing, harvesting, processing, packaging, transporting, selling, and consuming food. Risks to both food safety and availability occur at each point in the food system. The farm-to-table continuum is a visual tool that shows how farmers, food manufacturers, transporters, retailers, and you, the consumer—following regulations and guidelines from the U.S. government—can help ensure a safe food supply. Figure 20.7 shows the steps in this continuum.

farm-to-table continuum Illustrates the roles that farmers, food manufacturers, food transporters, retailers, and consumers play in ensuring that the food supply, from the farm to the plate, remains safe.

◀ Figure 20.7 The Farm-to-Table Continuum Every step in the farm-to-table continuum plays an important role in reducing microbes and the spread of foodborne illness.

Farm: Use good agricultural practices. Farmers grow, harvest, sort, pack, and store their crops in ways that help reduce food safety hazards.

1

Processing: Monitor at critical control points. During processing, HACCP measures are implemented.

2

Transportation: Use clean vehicles and maintain the proper temperature. Food is kept at a proper temperature during transportation to reduce the growth of foodborne microbes.

3

Retail: Follow the Food Code guidelines. Retail outlets, including restaurants, grocery stores, and institutions (such as hospitals), use the Food Code guidelines to reduce the risk of foodborne illness.

4

Consumer: Always follow the four Cs of food safety (clean, combat cross-contamination, cook, chill). The consumer uses the four Cs to reduce the risk of foodborne illness.

5

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Several Government Agencies and Programs Protect the Food Supply In 1906 Congress charged the USDA with the responsibility for monitoring the safety of our nation’s food. Today, several federal agencies share the responsibility for food safety in the United States.50 Table 20.4 lists these agencies and summarizes the roles they each play in safeguarding foods. The Food Safety Initiative (FSI), begun in 1997, coordinates the research, inspection, outbreak response, and educational activities of the various government agencies.

An example of collaboration among these government agencies is FoodNet (www.cdc. gov/foodnet ), which is a combined effort of the CDC, the USDA’s Food Safety Inspection Service (FSIS), the FDA, and 10 state health departments. The program consists of active surveillance for foodborne diseases and related studies designed to help public health officials understand the cause and effect of foodborne diseases in the United States. The objectives of the program include determining the burden of foodborne illness in the United States, monitoring trends over time, assessing the incidence of foodborne illness and its relation to specific foods and settings, and developing interventions to reduce the overall burden of foodborne illness.

The CDC coordinates another program called PulseNet (www.cdc.gov/pulsenet), which is a national network of public health and food regulatory agency laboratories—including those at the CDC, USDA/FSIS, and FDA—designed to identify and contain foodborne illness outbreaks. PulseNet participants perform DNA fingerprinting, a sort of molecu- lar identification, on pathogenic bacteria. DNA fingerprinting uses the bacteria’s unique genetic code to identify different strains of pathogens. These “fingerprints” are submitted electronically to a database at the CDC and the information is available on demand to public health and food regulatory agencies. Finding similar strains of a bacterium in both a person and a food suggests a common source and potential connection. If similar pat- terns emerge at the same time in different states, this could indicate a potential outbreak. Once a suspicious foodborne illness outbreak is reported and a source is identified, several government agencies then work together to contain the disease.

The E. coli outbreak in spinach that occurred in the fall of 2006 is one example of how multiple government agencies work together to identify and contain an outbreak. The CDC, through its monitoring and surveillance programs, detected an outbreak of illness due to E. coli O157:H7 and immediately alerted the FDA. DNA fingerprinting was used by PulseNet to determine that all infected individuals had consumed the same strain of E. coli and to trace the strain to bagged raw spinach grown in California. The fingerprinting also allowed the agencies to link the tainted food to reported illnesses in 26 states. Once the source of the outbreak was confirmed, the CDC issued an official health alert about the outbreak, and the FDA advised consumers to stop eating raw spinach. Before the outbreak was over, more than 200 people had been infected, and more than half of them

Food Safety Initiative (FSI) Coordinates the research, surveillance, inspection, outbreak response, and educational activities of the various government agencies that work together to safeguard food.

DNA fingerprinting Technique in which bacterial DNA “gene patterns” (or “fingerprints”) are detected and analyzed to distinguish between different strains of a bacterium.

Agency Responsible for

USDA Food Safety and Inspection Service (FSIS)

Ensuring safe and accurately labeled meat, poultry, and eggs

Food and Drug Administration (FDA) Ensuring the safety of all other foods besides meat, poultry, and eggs

Environmental Protection Agency (EPA) Protecting you and the environment from harmful pesticides

Animal and Plant Health Inspection Service (APHIS)

Protecting against plant and animal pests and disease

Centers for Disease Control and Prevention Surveillance of foodborne disease

TABLE 20.4 Agencies that Oversee the Food Supply

How Is the Food Supply Protected? 749

had been hospitalized.51,52 Three individuals died and 31 developed hemolytic uremic syndrome from the outbreak. However, through the collaborative efforts and swift action of these federal and state agencies, the outbreak was contained in a short period of time and its impact was minimized.

Hazard Analysis and Critical Control Points (HACCP) is a program used to identify and control foodborne hazards that may occur in all stages of the food production pro- cess.53 The HACCP approach was first conceived in the 1960s when the U.S. National Aeronautics and Space Administration (NASA) asked a private food manufacturer to design the foods for space flights. Since then, the FDA and USDA have mandated HACCP programs for seafood, juice, and meat processing in the United States. The use of HACCP is recommended, but not mandated, for other food industries as well. HACCP includes seven principles that focus on the analysis of potential hazards associated with foods and the identification of critical control points in the production of a food so that preventative measures can be put in place to minimize risks. For example, procedures for monitoring temperatures throughout a food’s production need to be in place. Manu- facturers also apply food preservation techniques to some foods to make them safer for consumers. We discuss these techniques later in the chapter.

Issues regarding food safety are also important at retail establishments. Grocery stores and restaurants must comply with FDA regulations. The Food Code is a reference document published by the FDA that local, state, and federal regulators use as a model for the development of their own food safety rules and to be consistent with national food regulatory policy. The Food Code provides practical, science-based guidance, including HACCP guidelines, and provisions to help purveyors minimize foodborne illness.54

Food Manufacturers Use Preservation Techniques to Destroy Contaminants In addition to government efforts to help prevent foodborne illness, food manufacturers also work to safeguard food. Food preservation methods, some of which have been in use for thousands of years, include heating, canning, pickling, salting, drying, and freez- ing, all of which help to keep foods safe. At the same time, manufacturers’ use of newer techniques such as irradiation and chemical additives has expanded as consumers demand fast and convenient foods, new flavors, increased shelf-life, and improved textures.

Pasteurization and Canning Pasteurization is a process for destroying pathogenic bacteria in which liquid foods are heated to a prescribed temperature for a specified time. The process kills E. coli O157:H7, Salmonella, and Listeria monocytogenes, all of which can be present in raw milk. Pasteurization improves the quality of dairy products and keeps all products fresh for a longer period of time. In addition to dairy products, pasteurization is required for some juices like fresh apple juice and other foods. Unpasteurized juices must display a warning on the label to alert consumers.55

Canning is a process in which foods are packed into airtight containers and then heated to temperatures of 240–250°F (115.5–121.1°C) to kill microorganisms. The amount of exposure time to heat varies by the type of food, its acidity, and its density. Processing conditions are chosen to ensure that the foods are sterile while retaining the most nutrients.56

Commercial canning is regulated by the FDA and HACCP procedures, which virtu- ally eliminates foodborne illness. However, improperly home-canned products can be the source of Clostridium botulinum, one of the toxin-producing foodborne bacterial species mentioned earlier in this chapter. C. botulinum can survive in airless environments and create spores that are not destroyed at normal cooking temperatures (refer to Table 20.2 on page 744). A temperature higher than boiling water (212°F [100°C]) is needed to kill

food preservation Treatment of foods to reduce deterioration and spoilage and help prevent the multiplication of pathogens that can cause foodborne illness.

pasteurization Process of heating liquids or food at high temperatures to destroy foodborne pathogens.

spores Hardy reproductive structures that are produced by certain bacteria and fungi.

canning Process of packing food in airtight containers and heating them to a temperature high enough to kill bacteria.

The FDA, CDC, and USDA worked together to combat an outbreak of E. coli O157:H7 in 2006 that was traced to bagged prewashed spinach.

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these spores.57 Botulism, the foodborne illness caused by consumption of the botulism neurotoxin produced by Clostridium botulinum, can be deadly, as it can cause paralysis of respiratory and other muscles.58

Two newer preservation methods used to keep foods fresh are modified atmosphere packing (MAP) and high-pressure processing (HPP). MAP is a process during which the manufacturer modifies the composition of the air surrounding the food in a package, thereby extending shelf-life and preserving the quality of packaged fruits and vegetables.59 HPP is a method in which foods are exposed to pulses of high pressure that destroy microorganisms. Foods such as jams, fruit juices, fish, vacuum-packed meat products, fruits, and vegetables can be treated with HPP.60

Irradiation Foods can also be treated with ionizing radiation to kill pathogenic bacteria and parasites. During the process of irradiation, foods are subjected to a radiant energy source within a protective, shielded chamber called an irradiator. The energy from the radiant waves damages the DNA of the pathogens, causing defects in their genetic instructions. Unless the microbes can repair the damage, they die. Because pathogens differ in their sensitivity to irradiation, the process either kills all of them or greatly reduces their numbers, thus reducing the risk of foodborne illness.61 Unfortunately, irradiation can cause mutations in some bacteria and viruses and may lead to the development of irradiation-resistant strains of these pathogens.62

Irradiation is a cold process and does not significantly increase the temperature or change the physical characteristics of most foods, which helps prevent nutrient loss. Also, just as foods cooked in a microwave do not retain microwaves, irradiated foods do not retain the energy waves used during the irradiation process.63 Most of the irradiating energy passes through the food and the packaging without leaving any residue behind.64

Irradiation destroys bacteria such as Campylobacter, E. coli O157:H7, and Salmonella and helps control insects and parasites.65 It does not destroy viruses, such as norovirus and hepatitis A, or the prions associated with mad cow disease (BSE). The nucleic acid of viruses is too small to be destroyed, and prions—which are protein particles—do not have nucleic acids.

Irradiation can also stop the ripening process in some fruits and vegetables and reduce the number of food spoilage bacteria. Irradiated strawberries can last up to 3 weeks in the refrigerator, compared with only a few days for untreated berries.

Irradiated food has been evaluated for safety by the FDA for more than 30 years.66 Irradiation has been used for years to sterilize surgical instruments and implants and to destroy disease-promoting microbes in foods served to hospital patients who have weak- ened immune systems. However, the use of irradiation in foods is not widespread due to consumer concerns and the expense of building the facilities.

Since 1986, all irradiated products must carry the international “radura” symbol, along with the phrase “treated by irradiation” or “treated with radiation” on the pack- age (Figure 20.8). If a product such as sausage contains irradiated meat or poultry, these items must be listed as “irradiated pork” or “irradiated chicken” on the food label.67 A label is not required if a minor ingredient, such as a spice, has been irradiated and used in the product.

Irradiation cannot be used with all foods. It causes undesirable flavor changes in dairy products, egg whites tend to become milky and liquid, fatty meats may develop an odor, and it causes tissue softening in some fruits such as peaches, nectarines, and grapefruits. Foods that are currently approved for irradiation in the United States include fruits and vegetables; herbs and spices; fresh meat, pork, and poultry; wheat flour; and white potatoes.68

Although irradiation has many advantages, it doesn’t guarantee that a food is free from all pathogens, and some foods such as steak tartare (a dish that contains raw ground

modified atmosphere packaging (MAP) Food preservation technique that changes the composition of the air surrounding the food in a package to extend its shelf-life.

high-pressure processing (HPP) Method used to pasteurize foods by exposing the items to pulses of high pressure, which destroys the microorganisms that are present.

irradiation Process in which foods are placed in a shielded chamber, called an irradiator, and subjected to a radiant energy source; kills specific pathogens in food by breaking up the cells’ DNA.

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▲ Figure 20.8 FDA-Approved Uses of Irradiation The international radura symbol must appear on all irradiated foods.

Approved foods Controls insects

Fruits and vegetables Delays maturation

Spices and dry vegetable seasonings Decontaminates and controls insects and microorganisms

Meats (beef, lamb, pork) Controls spoilage and disease-causing microorganisms

Poultry Controls disease-causing microorganisms

Dry or dehydrated enzyme preparations Controls insects and microorganisms

beef) should still not be eaten raw, even if they have been irradiated. Irradiation comple- ments but does not replace the need for proper food-handling practices by food growers, processors, and consumers.

Product Dating Identifies Peak Quality Expiration dates on almost all food products, with the exception of certain poultry, baby food products, and infant formulas, are provided voluntarily by food manufacturers and are not required by federal law. However, currently more than 20 states require some form of mandatory food product dating.

There are two types of food product dating: closed dating and open dating. Closed (or coded) dating refers to the packing numbers used by manufacturers that are often found on nonperishable, shelf-stable foods, such as cans of soup and fruit (Figure 20.9a). The manufacturer uses this type of dating to keep track of date and time of production, product inventory, and the location of products in the event of a recall.69

Open dating is more useful for the consumer and is typically found on perishable items such as meat, poultry, eggs, and dairy foods. Open dating must include at least a month and a day, and if the product is shelf-stable or frozen, the year must also be included (see Figure 20.9b). Open dating can help consumers determine if a product is at its peak quality but not if it is safe to eat. For example, a carton of yogurt that has been mishandled and not refrigerated for several hours may be unsafe to eat even though the date on the container hasn’t passed.

Open-dated products must also contain a phrase next to the date that tells the con- sumer how to interpret it. If there is “Sell By” next to the date, the product should be purchased on or before that date. This date takes into consideration additional time for storage and use at home, so if the food is bought by the “Sell By” date it can still be eaten at a later date. If there is “Best if Used By” or “Use By” next to it, the date shows how long the manufacturer thinks a food will be of optimal quality. This does not necessarily mean that the product should not be used after the suggested date, as these dates refer to product quality, not safety.70

The Safety of the Water Supply Is Regulated The Environmental Protection Agency (EPA) is the government body responsible for ensuring that consumers have a safe water supply; the Safe Drinking Water Act (SDWA) is the principal federal statute that affords that protection. Health-based standards are

closed or “coded” dating Refers to the packing numbers that are decodable only by manufacturers and are often found on nonperishable, shelf-stable foods.

open dating Typically found on perishable items such as meat, poultry, eggs, and dairy foods; must contain a calendar date.

▲ Figure 20.9 Closed and Open Food Product Dating

Closed food product dating refers to the coded packing numbers that you often see on nonperishable foods such as canned soups.

a

Open food product dating must contain a calendar date and is used on perishable food items along with information on how to use the date.

b

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preservatives Substances that extend the shelf-life of a product by retarding chemical, physical, or microbiological changes.

set by the EPA to protect the drinking water in the United States from unsafe levels of contaminants. In most cases the EPA delegates to the states responsibility for ensuring that the health standards are met. The EPA collects and stores annual reports of each state’s drinking water in a database called the Safe Drinking Water Information System (SDWIS). If there is an immediate threat to consumer health due to violation of a drinking water standard, the SDWA requires that public water systems notify consumers through the media or mail.71

Lead is a naturally occurring element found in the soil, air, and water around our homes. Lead exposure from paint and pipes made with lead can be harmful. In children, even low levels of lead in the blood can impair cognitive development. Pregnant women exposed to lead are at risk of premature birth and reduced growth of the fetus, while other adults can experience cardiovascular and kidney dysfunction.72

Whereas a small amount of lead in public water is normal, the EPA declared a federal state of emergency when Flint, Michigan, residents were exposed to water containing high levels of lead. The exposure occurred when the city switched to the Flint River as its source for public drinking water. This water’s high acidity caused lead in the outdated municipal pipes to leach into the water. Residents were warned to use bottled water for drinking and bathing until the pipes could be replaced in 2020. The city’s slow response to the crisis contributed to the residents’ contamination and became the subject of national news.

LO 20.3: THE TAKE-HOME MESSAGE Several government agencies, including the FDA and USDA, share responsibility for food safety in the United States. HACCP is a food safety program used by the FDA, the USDA, and the food industry to identify and control hazards that may occur in any part of the food system. Manufacturers may use techniques such as pasteurization, can- ning, and irradiation to preserve food and destroy contaminants. The FDA has approved the use of irradiation in the U.S. food supply even though some con- sumers have concerns about the safety of irradiated foods. Most food product dating is provided voluntarily and can help determine peak quality but not food safety. The EPA is responsible for ensuring the safety of our water supply.

What Role Do Food Additives and Other Chemicals Play in Food  Production and Safety? LO 20.4 Compare the risks and benefits of food additives and the use of hor-

mones, antibiotics, and pesticides in both traditionally and organically grown food.

Food manufacturers use various types of food additives for many different reasons. Commonly used additives include preservatives (such as antioxidants and sulfites), nutri- ents, and flavor enhancers (such as MSG). Food producers also give food-producing animals hormones and antibiotics to improve the health and food yield of these animals, but they may cause unintentional side effects in consumers.73 Other food producers use pesticides on plants to protect them and boost production.

Some Additives Are Used to Preserve Foods Most food additives are preservatives that are added to foods to prevent spoilage (usually by destroying microbes) and increase shelf-life. The most common antimicrobial preserva- tives are salt and sugar. Salt has been used for centuries, particularly in meat and fish, to

food additives Substances added to food that affect its quality, flavor, freshness, and/or safety.

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create a dry environment in which bacteria cannot multiply. Most (65 percent) of the salt consumed in the United States comes from processed and prepared foods that you find in grocery and convenience stores.74 Sugar is used for the same preserving effect in products such as canned and frozen fruits and condiments.

Nitrites and nitrates are ionic salts, chemical compounds that result from the bond- ing of a positively charged ion to a negatively charged ion, that are added to foods to prevent microbial growth. They are used in cured meats such as hot dogs and hams to prevent the growth of Clostridium botulinum. These chemicals give processed meats their pink color. The use of these salts has been controversial because they form carcinogenic nitrosamines in the GI tract of animals.75

The addition of antioxidants to foods can prevent an off taste or off color in a product that’s vulnerable to damage by oxidation. Currently the antioxidant vitamins E and C are approved for use as food additives. Fat-soluble vitamin E is often added to oils and cereals to prevent rancidity. Water-soluble vitamin C is often added to cut fruit to prevent pre- mature browning. Butylated hydroxyanisole (BHA) and butylated hydroxytoluene (BHT) are chemical antioxidants that are also used as preservatives. Although some studies into BHT and BHA have linked high amounts to cancer, the current body of research evidence suggests that their use in foods is safe.76

Sulfites are a group of antioxidants that are used as preservatives to help prevent the oxidation and browning of some foods and to inhibit the growth of microbes.77 Sulfites are often found in dried fruits and vegetables, packaged and prepared potatoes, wine, beer, bottled lemon and lime juice, and pickled foods. For most people sulfites pose no risk, but sulfur dioxide causes adverse reactions in some people.78 The FDA has prohibited the use of sulfites on fruits and vegetables that are served raw, and foods containing sulfite additives or ingredients treated with sulfites must declare “added sulfites” in the ingredients list on the label. Food sold in bulk, such as dried fruit treated with sulfites, must display the ingredients on a sign near the food. Because sulfites destroy the B vitamin thiamin, the FDA prohibits their use in enriched grain products and other foods that are good sources of this vitamin.79

Some Additives Enhance Food Quality and Appeal Food manufacturers also use additives to increase the quality or appeal of their prod- ucts. Some additives improve food texture and consistency. Others enhance the nutrient content, color, or flavor of food. Table 20.5 lists some commonly used nonpreservative additives and their functions in foods.

nitrites and nitrates Substances that can be added to foods to function as a preservative and to give meats such as hot dogs and luncheon meats a pink color.

sulfites Preservatives used to help prevent foods from turning brown and to inhibit the growth of microbes; often used in wine and dried fruit products.

Dried fruits often have sulfur dioxide or other sulfites added to them to preserve color and flavor. People with sulfite sensitivity should avoid products containing these additives.

Additive(s) Function(s) Found in

Alginates, carrageenan, glyceride, guar gum, lecithin, mono- and diglycerides, methyl cellulose, pectin, sodium aluminosilicate

Impart/maintain desired consistency

Baked goods, cake mixes, coconut, ice cream, processed cheese, salad dressings, table salt

Ascorbic acid (vitamin C), calcium carbonate, folic acid, thiamine (B1), iron, niacin, pyridoxine (B6), riboflavin (B2), vitamins A and D, zinc oxide

Improve/maintain nutritive value Biscuits, bread, breakfast cereals, desserts, flour, gelatin, iodized margarine, milk, pasta, salt

Ascorbic acid, benzoates, butylated hydroxyani- sole (BHA), butylated hydroxytoluene (BHT), citric acid, propionic acid and its salts, sodium nitrite

Maintain palatability and wholesomeness

Bread, cake mixes, cheese, crackers, frozen and dried fruit, lard, margarine, meat, potato chips

Citric acid, fumaric acid, lactic acid, phosphoric acid, sodium bicarbonate, tartrates, yeast

Produce light texture and control acidity/alkalinity

Butter, cakes, cookies, chocolates, crackers, quick breads, soft drinks

Annatto, aspartame, caramel, cloves, FD&C Red No. 40, FD&C Blue No. 1, fructose, ginger, limo- nene, MSG, saccharin, turmeric

Enhance flavor or provide desired color

Baked goods, cheeses, confections, gum, spice cake, gingerbread, jams, soft drinks, soup, yogurt

Source: Adapted from FDA. 2014. Food Additives Status List. Available at https://www.fda.gov/food/ingredientspackaginglabeling/foodadditivesingredients/ucm091048.htm. Accessed April 2017.

TABLE 20.5 Commonly Used Food Additives

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Additives to Enhance Texture and Consistency Food additives can enhance the texture and consistency of food in a number of ways. Gums and pectins are often added to thicken yogurts and puddings. Emulsifiers improve the stability, consistency, and homogeneity of high-fat products like mayonnaise and ice cream. Lecithin is an example of an emulsifier that is often added to salad dressings. Leavening agents such as yeast or baking powder cause dough to rise before it’s baked. Anticaking agents such as sodium aluminosilicate and calcium carbonate prevent products like powdered sugar that are crystalline in nature from absorbing moisture and lumping. Humectants such as propylene glycol increase moisture in products so that they stay fresh.

Additives to Improve Nutrient Content Additives can be used to enhance a product’s nutritional content, such as when refined grains are enriched and fortified with added B vitamins (folic acid, thiamin, niacin, and riboflavin) and iron. In some cases, the federal government mandates such additions. This was the case in 1996, when the FDA published regulations requiring the addition of folic acid to enriched breads, cereal, and other grain products in order to help decrease the risk of neural tube defects in newborns.

Additives to Improve Color Additives can also enhance the color of foods. There are two main categories that make up the FDA’s list of permitted colors. “Certifiable” color additives are man-made and are derived primarily from petroleum and coal. You can recognize these types of additives by the following prefixes: FD&C, D&C, or Ext. An example is FD&C Yellow, which is often found in cereals and baked goods. The second main category of color additives is obtained largely from plants, animals, or minerals. Examples include caramel and grape color extract.

Adverse physical or allergic reactions to color additives are rare, although FD&C Yellow No. 5 may cause itching and hives in some people. This additive is found in bever- ages, desserts, and processed vegetables and must be listed as an ingredient on food labels.

MSG to Enhance Flavor Monosodium glutamate (MSG) is the sodium salt of glutamic acid, a nonessential amino acid, and is often used as a flavor enhancer in Asian foods, canned vegetables and soups, and processed meats. Consumers can buy it in a form that is similar in texture to salt. Although it doesn’t have a strong taste of its own, it enhances sweet, salty, sour, and bitter tastes.

After an extensive review, the FDA confirmed that MSG is safe to consume in the amounts typically used in processed foods and cooking (a typical meal that contains MSG has less than 0.5 gram). However, when consumed in large quantities such as 3 or more grams at a time, it may cause short-term reactions in people who are sensitive to it.80 These reactions, which are called the MSG symptom complex, can include numbness, a burn- ing sensation, facial pressure or tightness, chest pain, rapid heartbeat, and drowsiness. In addition, people with asthma may have difficulty breathing after consuming MSG. For these reasons, the FDA requires that all foods containing MSG declare this ingredient on the food label.

Food Additives Are Regulated by the FDA Food additives are strictly regulated by the FDA, with consumer safety a top priority. The Federal Food, Drug, and Cosmetic Act of 1938 gave the FDA authority to regulate food and food ingredients, including the use of food additives. The 1958 Food Additives Amendment further mandated that manufacturers document a food additive’s safety and obtain FDA approval before using it in a food.81

monosodium glutamate (MSG) Sodium salt of glutamic acid, used as a flavor enhancer.

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Two categories of food additives were exempted from this amendment. The first category includes substances that were known to be safe before 1958 and were given prior-sanctioned status.82 For example, because nitrates were used to preserve meats before 1958, they have prior-sanctioned status, but only for their use in meats. They can’t be used in other foods, such as vegetables, without FDA approval. The second category includes substances that have a long history of being safe for consumption, such as salt, sugar, and spices, or have extensive research documenting that they are safe to consume, such as vitamins and MSG. These additives are categorized as generally recognized as safe (GRAS) and are exempt from FDA approval.83

The FDA continually monitors both prior-sanctioned additives and those with GRAS status to ensure that current research continues to support their safety. To remain on the GRAS list, an additive must not have been found to be carcinogenic in animals or humans and must be safe for human consumption. The 1958 Food Additives Amendment also included the DeLaney Clause, which states that no substances that have been shown to cause cancer in animals or humans at any dosage may be added to foods. However, with the present increases in technology and the ability to detect substances at very low levels, the clause is considered outdated. To address this issue the FDA deems additives safe if lifetime use presents no more than a one-in-a-million risk of cancer in human beings. If an additive is suddenly called into question, the FDA can prohibit its use or require that the food manufacturer conduct additional studies to ensure its safety.

The food additives discussed in the preceding sections are all intentional food addi- tives used to improve the quality of food products. However, the FDA also regulates unintentional food additives, very small amounts of substances that enter foods during packaging or processing. For example, dioxins used during the manufacture of bleached paper such as coffee filters may end up in coffee and other foods and beverages. Dioxins can accumulate in the food chain and are carcinogenic to animals. The FDA requires that dioxin levels in products be so low as to present no health risks to people.84

Hormones and Antibiotics Are Provided to Food-Producing Animals Hormones and antibiotics are two classes of compounds that are sometimes used to improve the health or output of food-producing animals. While the use of these sub- stances is intentional, the resulting changes in the final food product are not, and these changes are a subject of controversy and consumer concern.

Bovine Growth Hormone Cows naturally produce bovine growth hormone (BGH), also known as bovine somatotropin. Some dairy farmers and ranchers treat their cattle with the naturally occurring form of BGH in order to produce animals that are leaner and produce more milk. Scien- tists can also produce a synthetic version of the hormone, recom- binant bovine somatotropin (rBST), and cows injected with this form can produce up to 25 percent more milk than untreated cows.85

Consumer groups and Health Canada (the FDA equivalent in Canada) have questioned the long-term safety of rBST. Traces of both the synthetic and natural form of BGH remain in the meat and milk of cows, and milk from rBST-treated cows has higher levels of IGF-1, a hormone that normally helps some types of cells to grow.86 The FDA’s extensive review of the safety of the use of rBST has found no evidence that it poses any long-term health threat to humans.87 However, consumer concerns over the long-term safety

prior-sanctioned Substances that the FDA had determined were safe for use in foods prior to the 1958 Food Additives Amendment.

generally recognized as safe (GRAS) Designation given by the FDA to substances intentionally added to food, indicating that the substance is considered safe by experts and is exempted from further testing.

DeLaney Clause Clause in the Food Additives Amendment mandating that additives shown to cause cancer at any level must be removed from the marketplace.

intentional food additives Substances added intentionally to foods to improve food quality.

unintentional food additives Substances that enter into foods unintentionally during manufacturing or processing.

bovine growth hormone (BGH) Hormone that is essential for normal growth and development in cattle.

recombinant bovine somatotropin (rBST) Synthetically made hormone identical to a cow’s natural growth hormone, somatotropin, that stimulates milk production; also known as rBGH (recombinant bovine growth hormone).

Natural bovine growth hormone, or its synthetic version, are sometimes injected into cows to increase milk production.

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of rBST has led to a decrease in the percent of milk produced in the United States from cows treated with rBST.

Other steroid hormones are sometimes used to increase the amount of weight that cattle gain and the amount of meat they produce and to increase milk production in dairy cows. The FDA has approved the use of these hormones in cattle, as they have been shown to be safe at their approved level of use and not a health concern to consumers.88 However, meat and milk that carry the USDA Organic seal cannot come from cows that were treated with these hormones.

Antibiotics Antibiotics are sometimes given to livestock for three purposes: (1) to treat animals that are sick, (2) to prevent disease, and (3) to promote growth. When antibiotics are used properly in the treatment of sick animals and to prevent the spread of disease, they are used for a relatively short period of time. However, when used to promote growth and increase the amount of meat and milk produced, they are used over a long period of time.

Pathogenic bacteria such as Campylobacter, E. coli O157:H7, and Salmonella are com- monly found in the GI tracts of animals without making them sick. The long-term use of antibiotics in animals can, however, promote the growth of strains of these bacteria that are antibiotic-resistant; that is, the bacteria develop features that make them unaffected by the administration of conventional antibiotic medications.89 This practice poses a risk to anyone who contracts a foodborne infection from the resistant bacteria and is treated with the same antibiotic used to treat the animals. The antibiotic will not destroy the “super bug” because it has developed resistance to the antibiotic during its chronic use in the animals. For example, an outbreak of Campylobacter-induced foodborne illness in humans was found to involve a “super-bug” strain of Campylobacter that was resistant to treatment with fluoroquinolone, a conventional antibiotic that had been regularly added to animal feed.90 Health care providers treating infections caused by resistant bacteria must use more powerful antibiotics and/or a longer treatment period.91

In 2015 the FDA implemented an update to the veterinary feed directive (VFD), which allows caregivers to use animal feed containing drugs. The new rule requires use of prescription drugs with the oversight of a veterinarian. It thereby helps ensure the judi- cious use of antibiotics in animals used for food.

Label Terms Indicate How Foods from Animals Are Produced Both the FDA and USDA are the consumer watchdogs for food labeling, and label- ing of foods from animals is essential when it comes to determining how the animals were fed, housed, and treated. The label terms for meat and poultry are determined and defined by the USDA. The following list includes terms often found on prepackaged meat products:92

• No Hormones (pork or poultry). Hormones are not allowed in raising hogs or poultry. Therefore, the claim “no hormones added” cannot be used on the labels of pork or poultry unless followed by the statement, “Federal regulations prohibit the use of hormones.”

• No Hormones (beef). The phrase “no hormones administered” may be approved for use on the label of beef products if no hormones have been used in raising the animals.

• No Antibiotics. May be used on labels for meat or poultry products if the animals were raised without antibiotics.

• Certified. Indicates that the USDA has evaluated a meat product for class, grade, or other quality characteristics (e.g., “Certified Angus Beef”).

• Fresh Poultry. Poultry that has never had an internal temperature below 26°F (-3.3°C).

antibiotics Drugs that kill or slow the growth of bacteria.

antibiotic-resistant bacteria Bacteria that have developed a resistance to an antibiotic such that they are no longer affected by it.

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• Free Range. Producers must demonstrate that the animal has been allowed access to the outdoors.

• Kosher. Meat and poultry products that were prepared under the supervision of a rabbi.

• Natural. The food contains no artificial ingredient or added color and is only minimally processed; that is, using processes that do not fundamentally alter the raw product. The label must explain the use of the term natural (such as “no added colorings or artificial ingredients”).

Pesticides Are Widely Used in Agriculture Pesticides are used to prevent plant disease and insect infestations and can be applied to crops in the fields or after harvest. These chemicals increase crop yield by controlling threats to the food supply. Despite the beneficial role that they play in ensuring consum- ers a wide variety of foods, concerns about pesticides in food persist. The EPA continues to evaluate the safety of each pesticide used on food every 15 years. The Food Quality Protection Act (FQPA) ensures that all pesticides meet strict safety standards.93

Types of Pesticides Several different types of pests can diminish or destroy crop yields, including weeds, insects, microorganisms (bacteria, viruses), fungi (mold), and rodents (rats and mice). Her- bicides are a type of pesticide used to kill weeds, insecticides kill insects, antimicrobials are used on microorganisms, fungicides are used to destroy mold, and rodenticides poison and kill rodents.

Pesticides can be biologically or chemically based. Biologically based pesticides, such as biopesticides and sex pheromones, use material from animals, plants, bacteria, and some minerals and are typically less toxic than chemical pesticides.94 Unlike chemical pesticides, biopesticides only harm a specific pest, and thus are not harmful to birds and other animals that may come into contact with them. For example, baking soda can be diluted with water and sprayed on plants to inhibit the growth of fungi without risk to animals or humans. Insect sex pheromones can be used to interfere with the reproduction of insects known to harm plants.

Chemically based organophosphates make up about half of all insecticides in the United States and are used on fruits, nuts, vegetables, corn, wheat, and other crops, as well as on commercial and residential lawns and plants. They are also used to help control mosquitoes and termites.95 These pesticides kill pests by affecting their nervous systems, and exposure to humans may have effects on our nervous systems as well.

Antimicrobials, a special type of chemical pesticide that includes disinfectants and sanitizers, are used to destroy and control the spread of microorganisms on surfaces or objects, such as walls, countertops, and floors.96 Sanitizers are often used in addition to washing with soap and water in food processing plants and in restaurants. Waterless, alco- hol-based hand gels that are useful against pathogens are approved by the FDA for use in health care settings but are not approved for use in foodservice and retail establishments. Alcohol-based hand gels do not kill all types of pathogens, though using an antimicrobial hand gel is better than nothing when water and soap are not available for handwashing.97

Risks of Pesticides Chemically based pesticides are not without risks to animals, the environment, and even humans. Residues of these chemicals remain on fruits and vegetables that reach consum- ers, and infants and young children are particularly susceptible to their hazards. Although a recent EPA review concluded that exposure to organophosphates in food and water to people in the United States likely causes no harm,98 the EPA has also found that certain pesticides, depending on their level of toxicity and how much is consumed, may cause serious health problems, such as cancer, birth defects, and nerve damage.99

pesticides Substances that kill or repel pests such as insects, weeds, microorganisms, rodents, or fungi.

herbicides Substances that are used to kill and control weeds.

insecticides Pesticides used to kill insects.

antimicrobials Substances or a combination of substances, such as disinfectants and sanitizers, that kill or inhibit the growth of microorganisms.

fungicides Chemicals used to kill mold.

rodenticides Poisons used to kill rats, mice, and other rodents.

organophosphates Group of synthetic pesticides that adversely affect the nervous systems of pests.

Farmers use pesticides on food crops to diminish the damage from pests such as weeds or insects.

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To address these issues, Healthy People 2020 includes an objective focused on reducing the number of health care visits related to pesticide exposure per year and advocates a reduction in the use of certain potentially dangerous pesticides.100 In addi- tion, the American Academy of Pediatrics has urged the U.S. government to improve public education, workplace training, science-based research, and the ongoing surveillance of pesti- cide usage.101 In order to protect public health and the environ- ment, the types of pesticides and how often they can be used, as well as the amount of residue that can remain on foods when they reach consumers, are heavily regulated in the United States.

Regulation of Pesticides The EPA requires extensive test data from pesticide producers demonstrating that pesticide products can be used with “a rea- sonable certainty of no harm.” To determine this, the EPA uses a four-step human health risk assessment that includes hazard identification, dose–response assessment, exposure assessment, and risk characterization (Figure 20.10).

The first step, hazard identification, identifies the poten- tial hazards or ill effects that may develop after exposure to a specific pesticide. Tests looking at a wide range of side effects,

from eye and skin irritations to more serious health effects such as cancer, are often performed on laboratory animals.

Because “the dose makes the poison,” the second step, dose–response assessment, determines the dose levels at which adverse effects occur in animals and then uses this information to calculate a potentially equal dose in humans.

The third step, exposure assessment, determines all the ways that a person could typically be exposed to that specific pesticide. Most foods are grown with the use of pesticides, so one route of exposure is through eating food. Some pesticides applied to farmland make their way into drinking water supplies, which is another route of exposure. Exposure could also occur through inhalation or absorption through the skin when using household disinfectants or gardening pesticides around the home. The EPA has a separate program for assessing occupational risk and the level of expo- sure that pesticide applicators and vegetable and fruit pickers face due to the nature of their jobs.

The fourth and last step, risk characterization, is the process of combining the hazard, dose–response, and exposure assessments to determine the pesticide’s overall risk. Using the conclusions of a risk assessment, the EPA can make an informed decision regarding whether to approve a pesticide or chemical for use freely or with restrictions.102

Acceptable tolerance levels are set using a margin of safety due to the potential dif- ferences that exist between the effects of a pesticide on animals and its effect on humans, as well as differences among humans. A safety factor of tenfold or less, depending on the evidence, is added to protect the most vulnerable groups, such as infants and children, for whom the same amount of pesticide provides a larger dose per unit of body weight than for adults.103 Thus, much effort goes into ensuring that the food supply is safe, yet affordable, so that consumers obtain foods that are nutrient dense while being exposed to a minimum amount of pesticide.

In addition to the EPA, the USDA and the FDA are also involved in regulating pesticides. The EPA is charged with approving pesticides for their specific usages, regulat- ing how much of the pesticide can be used, and establishing acceptable tolerance levels. The USDA enforces the tolerance levels for meat, poultry, and eggs, and the FDA enforces tolerance levels for all other foods.104

risk assessment Process of determining the potential human health risks posed by exposure to substances such as pesticides.

acceptable tolerance levels Maximum amount of pesticide residue that is allowed in or on foods.

▲ Figure 20.10 EPA’s Four-Step Risk Assessment Process This four-step process is used by the EPA to assess risk of pesticides to humans. Source: Adapted from Environmental Protection Agency. 1991. Risk Assessment for Toxic Air Pollutants: A Citizen’s Guide. Available at https://www3.epa.gov/airtoxics/3_90_024. html. Accessed April 2017.

Hazard identification What health problems are caused by the pollutant?

Risk characterization What is the extra risk of health problems in the exposed population?

Exposure assessment How much of the pollutant do people inhale during a specific time period? How many people are exposed?

Dose-response assessment

What are health problems at different exposures?

What Role Do Food Additives and Other Chemicals Play in Food  Production and Safety? 759

Alternatives to Pesticides One method that some growers use to manage pests in their crops is integrated pest man- agement (IPM), which emphasizes the use of the most economical methods to control pests while causing the least risk of harm to the consumer, the crops, or the environment. Growers using the IPM approach use preventative measures, such as rotating crops, choos- ing pest-resistant strains of plants, and planting nonfood crops nearby to lure away pests.105 When an infestation occurs, IPM programs are allowed to use targeted spraying of chemical pesticides as a last resort. Most crops in the United States are grown using at least a minimal form of IPM in which farmers identify pests and use a targeted pesticide to treat them.106

Minimizing Pesticides in the Diet More than 80 percent of the pesticide residue remaining on the skins of fruits and veg- etables can be removed simply by washing them with clean, running water and scrubbing them with a vegetable brush.107 Peeling the skin from fruits and vegetables can help reduce pesticide residues and harmful microbes, but it also eliminates some of the fiber and micronutrients. For leafy vegetables such as cabbage and lettuce, the outer leaves can be removed and discarded to minimize risk. Consumers should also be aware that because of the strict pesticide guidelines in place in the United States, the amount of pesticide residue on fruits and vegetables should be below the EPA acceptable tolerance levels even before they reach the market.

Eating a variety of produce from a variety of locations also minimizes the consumption of any one type of pesticide. Although people who eat more fruits and vegetables potentially increase their exposure to pesticides, they still typically have a lower risk of cancer than those who eat fewer fruits and vegetables.108 Locally grown produce may contain fewer pesticides than shipped produce because it does not contain pesticides applied to extend shelf-life. See Figure 20.11 for a summary of strategies to minimize pesticides in the diet.

Organic Foods Meet USDA National Organic Standards Organic food production involves growing food using approved methods that integrate cultural, biological, and mechanical practices that conserve resources, promote ecologi- cal balance, and conserve biodiversity.109 Organically grown foods are grown without

integrated pest management (IPM) Agricultural technique that uses the most economical and the least harmful methods of pest control to minimize risk to consumers, crops, and the environment.

organic Being free of chemical-based pesticides, synthetic fertilizers, irradiation, and bioengineering; a USDA-accredited certifying inspector must certify organic foods.▲ Figure 20.11 Reducing Pesticides in Foods

Wash: Thoroughly wash and scrub all fresh fruits and vegetables under running water to dislodge bacteria and some of the pesticide residue. Running water is more effective for this purpose than soaking the fruit and vegetables.

Peel and trim: Peeling fruits and vegetables and discarding the outer leaves of leafy vegetables helps reduce pesticides. Trimming the visible fat from meat and the fatty skin from poultry and fish helps reduce some of the pesticide residue that remains in the fatty tissue of the animal.

Eat a variety of foods: Eating a variety of foods reduces the chance of being overexposed to any particular pesticide.

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the use of most synthetic pesticides, synthetic fertilizers, bioengineering, or irradiation. Only antibiotic-free or growth hormone–free animals can be used to produce organic meat, poultry, eggs, and dairy foods.110 Many consumers choose organically grown foods over traditionally grown foods because they are concerned about exposure to pesticides and other chemicals or perceive organic foods to be healthier. Consequently, consumer demand for organically grown products continues to increase. The annual growth rate of organically grown foods was 11 percent in 2015.111 Organically grown foods are big business and annual sales of organically grown products topped $43.3 billion in 2015, according to a survey on the organic food industry from the Organic Trade Association.112

The Organic Foods Production Act and the National Organic Standards (NOS) developed in 2002 by the USDA are intended to ensure that the organic foods consum- ers purchase are produced, processed, and certified consistent with national standards.113

The NOS provide specific criteria that food producers must meet during production, handling, and processing in order to label their products USDA organic. These standards define substances both approved for use and prohibited from use in organic food produc- tion. For example, organically grown foods cannot be grown using sewage sludge, and a USDA-accredited inspector must certify the farming and processing operations that produce and handle foods labeled as organic.114

Consumers who purchase organically grown and processed foods should not assume that they are pesticide free. Organically grown crops may come into contact with chemi- cals due to drift from wind and rainwater. Also, though organic farmers use IPM, and grow more disease- and pest-resistant plants, they can also use synthetic pesticides and biopesticides to control weeds and insects. Allowed synthetic pesticides include certain insecticidal soaps, microbials, botanicals, and minerals, whereas some natural substances, such as ash from the burning of manure, are prohibited from use in organic farming.115

There is no conclusive evidence that organically grown foods are nutritionally supe- rior to foods grown using conventional methods.116,117 Although organically grown foods differ in the ways they are grown, handled, and processed, and these differences do reduce exposures to pesticide residues, growth hormones, and antibiotic-resistant strains of bacte- ria, they do not appear to result in significant differences to the nutrient content of food.118 A balanced and varied diet can support health regardless of whether the foods were grown organically or conventionally.

The USDA strictly regulates labeling of organic foods. Foods that display the USDA Organic Seal (Figure 20.12) or otherwise state that they are organic must contain at least 95 percent organic ingredients. A food label can state, “Made with Organic Ingredients” if it contains at least 70 percent organic ingredients. Labels of foods with less than 70 percent organic ingredients can make no organic claims.

▲ Figure 20.12 The USDA Organic Seal Foods that are labeled or advertised with the USDA Organic Seal must contain at least 95 percent organic ingredients.

LO 20.4: THE TAKE-HOME MESSAGE The FDA strictly regulates all compounds intentionally added to foods or provided to food-producing animals. Food addi- tives have long been used for food preservation and are often used by modern manufacturers to enhance texture, color, flavor, or nutrient content. Growth hormone is often given to dairy cows to increase milk production. Animal feed containing low doses of antibiotics has been used to increase the growth of cattle, poultry, and pigs, but can lead to the development of antibiotic-resistant strains of bacteria. All intentional food additives must be listed on food labels. Pesticides are used to destroy or mitigate pests and increase crop yield. Con- sumers can minimize exposure to plant pesticides by washing and trimming foods during preparation and by eating a wide variety of foods. The USDA developed National Organic Standards (NOS) that help to assure consumers that foods labeled as USDA organic are grown without the use of most syn- thetic pesticides, synthetic fertilizers, bioengineering, or irradiation.

What Is a Sustainable Food System? 761

What Is a Sustainable Food System? LO 20.5 Explain what constitutes a sustainable food system.

There are currently more than 7 billion people in the world and that number is expected to increase by 2 billion people by 2050.119 How will we provide safe and nutritious food for the growing number of people, given the limited resources available? This question deserves our attention and will require changes at all levels of our current food system.

A sustainable food system is one that can be maintained indefinitely without deplet- ing or polluting natural resources. According to the position of the Academy of Nutrition and Dietetics, sustainable food systems conserve, renew, and protect natural resources; empower social responsibility to uphold the system; and are economically viable because they build community wealth (Figure 20.13).120 All food systems are affected by social, political, economic, and environmental factors and depend on both human and natural resources. Sustainable food systems produce food using minimal natural resources, such as soil and water, and transport food using minimal energy. Thus, a sustainable diet con- tains foods that are produced in ways that are ecologically neutral.

Numerous natural resources, of two types, are used when growing crops and raising animals for food. Internal natural resources are used to produce foods. External natural resources are used to move food products from the farm to the consumer. Both internal and external resources generate natural and man-made by-products that affect the environment.

sustainable Referring to a method of resource use that can be maintained indefinitely because it does not deplete or permanently damage the resource.

▲ Figure 20.13 Sustainable, Resilient, and Healthy Food and Water Systems Framework Source: A. Tagtow, K. Robien, E. Bergquist, M. Mruening, L. Dierks, B. E. Hartman, et al. 2014. Academy of Nutrition and Dietetics: Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems. Journal of the Academy of Nutrition and Dietetics 114(3):475–488.

Sustainable, Resilient, and Healthy Food

and Water Systems

Nutrition and Health •Assures dietary diversity •Assures safety of food and water supplies •Assures optimal access to food and water in order to meet nutritional requirements

Economic Vitality •Builds community wealth •Is economically viable and sustainable

Environmental Stewardship •Conserves, protects, and renews natural resources (soil, water, air, energy, biodiversity) •Supports vibrant ecosystems •Promotes a low-carbon footprint •Mitigates climate change

Social, Cultural, and Ethical Capital •Promotes cultural diversity •Empowers social responsibility and community engagement

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Preserving Internal Natural Resources Is the First Step toward Sustainability Abuse of any of the natural resources required to grow foods can prevent sustainability. Soil, biodiversity, energy, and water are the key internal natural resources that must be preserved in a sustainable food system. Table 20.6 describes several of the challenges associated with using internal resources, including land and water, to produce food, and various strategies that can be employed to protect the environment.

Soil More than a billion tons of topsoil, the layer of soil that sits atop the earth’s crust, is lost each year from erosion.121 It’s not surprising, then, that numerous experts are concerned about soil degradation. All land organisms ultimately depend on the earth’s soil. Organisms within the soil, such as bacteria and other microorganisms, feed on the nutrients provided by animal waste products and decaying plant and animal mat- ter. Plants use nutrients in the soil to grow and to produce fruits, vegetables, nuts, and seeds. Humans and animals later obtain these same nutrients when they eat the plants and plant products.

Just as all organisms depend on healthy soil for survival, healthy soil depends on the organisms to anchor it in place and to keep it well oxygenated. Plant roots help hold soil in place, which protects it from water and wind erosion, and they also break up the soil to allow the dispersal of oxygen. As topsoil is formed and regenerated from decaying plants, organisms, animals, and rocks, a perpetual web of dependency is formed.

The Effect The Challenge How Can We Minimize the Environmental Impact?

Land overuse Excessive use of farming equipment, overtilling, and live- stock overgrazing can all damage soil.

Proper land management and conservation methods of tilling can help preserve the land and replenish soil nutrients.

Soil erosion Wind and rain can cause more than 1.5 billion tons of nutrient-rich topsoil to be blown and washed away each year. When fertile topsoil is lost, crop yield declines.

Proper crop covering and shielding from wind as well as proper tillage of the soil can dramatically reduce erosion.

Water depletion Irrigation accounts for 80 percent of water consump- tion in the United States; hence, excessive irrigation can deplete naturally occurring groundwater.

Precision farming and the conscious reduction of over- watering can help preserve water.

Water runoff After a rainfall (or watering of crops), the water runoff from farms can spread pesticides from crops and patho- gens in animal manure to other fields, surface water, and downfield rivers and streams, contaminating these ecosystems.

Basins can be installed to collect the runoff water to prevent contamination prior to discharge to streams and rivers.

Airborne emissions Emissions of ammonia and nitrogen in manure are released into the air. The ammonia released from these airborne emissions can settle on water surfaces, killing fish and encouraging the growth of toxic algae, both of which disrupt the natural ecosystem.

The proper handling of manure (see below) mitigates this problem.

Nitrate production The production of nitrates from the nitrogen in manure can pollute surface water and groundwater that is used as drinking water.

Proper collection, stockpiling, and disposal of manure to minimize the leaching of nitrates into runoff and ground- water, as proposed in the latest EPA regulations, helps concentrated animal feeding operations (CAFOs) to safely manage manure.

Sources: Data from A. H. Harmon and B. L. Gerald. 2007. Position of the American Dietetic Association: Food and Nutrition Professionals Can Implement Practices to Conserve Natural Resources and Support Ecological Sustainability. Journal of the American Dietetic Association 107:1033–1043; US Department of Agriculture, Economic Research Service. 2016. Irrigation and Water Use. Available at https://www.ers.usda.gov/topics/farm-practices-management/irrigation-water-use.aspx Accessed April 2017; U.S. Environmental Protection Agency. 2015. Ag 101: Beef Production. Available at https://www.epa.gov/sites/production/files/2015-07/documents/ag_101_agriculture_us_epa_0.pdf. Accessed April 2017.

TABLE 20.6 Environmental Effects of Food Production

What Is a Sustainable Food System? 763

Problems arise when the topsoil can’t be regenerated and/or is less fertile. When this happens plants cannot grow, the web is severed, and nourishment for the local microorganisms, plants, animals, and humans is reduced. The natural process of regenerat- ing one inch of nutrient-rich topsoil takes more than 500 years.122 Improper agricultural practices that facilitate erosion of soil faster than it can be regenerated disrupt the entire web and food system.123 However, research shows that crop rotation and other aspects of organic farming result in less soil erosion than conventional farming methods.124

Biodiversity Achieving and maintaining biodiversity is an important part of a sus- tainable food system, and the extinction of even one member of the web can have dramatic consequences. Since 2006 the United States has seen the rapid decline in the honeybee population, termed colony collapse disorder, which has reduced the pollination, and therefore availability, of fruits, veg- etables, and tree nuts (an estimated 30 percent of the foods that you eat need pollination to flourish).125 Lack of biodiversity among aquatic systems is also a potential problem. More than 60 percent of commercial fisheries are overharvested, endangering the existence of more than 30 percent of native fish in North America.126 As biodiversity is reduced, the variety and nutritional quality of foods available may also be reduced.

Energy Research suggests that around 15 percent of the total energy consumption in the United States is used in the production, processing, transport, and preparation of our food.127 Much of this is consumed as an external resource during processing and transport; however, some is used as an internal resource during the growth and production of food. For example, more energy (as well as land and water) is required to produce a meat-based diet than to produce a plant-based diet.128 In order to produce every pound of animal protein in the form of edible beef, 10.6 pounds of plant food and 8 gallons of water in the form of feed are required.129 Allowing livestock to graze on pasture rather than feeding them a grain diet would cut the amount of fuel needed to produce and transport feed grain in half. Producing chemical fertilizers and pesticides for crops also requires large amounts of fossil fuels.130 Avoiding these chemicals and using natural fertilizers, such as animal manure, not only cuts the use of fossil fuel, but also can make soil more fertile.131

Water According to the EPA, since the 1950s, the population in America has nearly doubled and our water consumption has more than tripled.132 This heightened demand for water is a danger not only to the environment but also to your health. You need water to sur- vive; therefore, conserving water now to ensure a healthy supply in the future makes sense.

In 2016 more than 40 percent of America’s total water use went to toilets and showers.133 In order to reduce this water waste, the EPA sponsors Water Sense, which is a voluntary label that manufacturers, retailers, and distributors can use to indicate that their models use at least 20 percent less water than regular product models.134 If all households installed water-efficient fixtures, the United States would save more than 3 trillion gallons of water annually.135 Other steps you can take to reduce water waste include using water- saving washing machines and dishwashers, taking short showers, and turning off the tap while washing dishes or brushing your teeth.

Plants draw nutrients from the soil through their roots, which in turn help anchor the soil in place, preventing erosion.

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Locally Grown Food Requires Fewer External Natural Resources External natural resources used to move food products from the farm to the consumer can contribute greatly to the environmental costs of food production. For example, the use of fos- sil fuels to grow, process, and transport food contributes to the release of carbon dioxide gas emissions. The carbon dioxide and other gases released when fossil fuels are burned for energy are referred to as greenhouse gases, as these gases absorb and trap heat in the air and re-radiate that heat downward. Global temperature has increased by 1.4°F since the 20th century and continues to increase because of the release of these greenhouse gases.136 Carbon emissions associated with the transport of food from farm to supermarket are substantial, and consum- ers use additional fuel to drive to the supermarket and to prepare food at home. The amount of fossil fuel used to transport that produce all those miles, coupled with the increase in carbon dioxide gas emissions into the air from burning that fuel, has enormous environmental costs.

Natural resources aside, these fuel costs are factored into the price of the food, so they affect consumers’ financial resources. A percentage of your food dollars goes toward the cost of getting food from the farm to your plate, though fuel is used in other aspects of food production as well.137 And as the price of fuel increases, the price that you pay for food increases. Thus, the farther your food has to travel, the more resources it uses, which not only has a negative effect on the environment, but also is a drain on your wallet.

Because of the environmental and financial costs of shipping foods over long dis- tances, some people are becoming locavores. Locavores try to buy from local farms, farmers markets, and roadside stands rather than supermarkets. They may have difficulty consuming 100 percent of their diet from local sources year round. For example, although Vermonters have access to fresh dairy foods 365 days a year, robust fruit and vegetable crops are hard to find under a foot of snow in the winter. Depending on where they live, loca- vores may have to supplement with foods from the supermarket. Farmers markets are an important resource for people who value food grown locally. See the Spotlight on page 765.

Many large supermarkets now sell locally grown produce. This combining of locally grown foods with conventionally grown foods allows consumers to do “one-stop shopping” rather than have to drive to farmers markets, farm stands, or community- supported agriculture (CSA) pickups in addition to the supermarket. Corporate America is also making it easier to eat locally. Some large corporations and industrial complexes have weekly farmers markets on their premises. Employees can shop for locally grown foods during the day and head home with the fixings for dinner.138 The USDA recently awarded more than $5 million in grants to support local food connections between farmers and con- sumers, even in large cities, with its “Know Your Farmer, Know Your Food” initiative.139

Some individuals wrongfully assume that locally grown food is the same as sustainably grown food. A sustainable diet contains foods that meet your nutrient and health needs but can be produced for a long time without negatively affecting the environment.140 Buying food from small local farms doesn’t guarantee that the foods were grown in a sustainable way, nor does being from a distant farm mean that those farmers didn’t practice sustainable agriculture.

locavore Person who eats locally grown food whenever possible.

community-supported agriculture (CSA) Arrangement where individuals pay a fee to support a local farm, and in exchange receive a weekly or biweekly box of fresh produce from the farm.

LO 20.5: THE TAKE-HOME MESSAGE A sustainable food system is one that will survive over the long term. To maintain a sustainable food system, the natural resources used to produce, transport, and distribute the food are conserved instead of being destroyed or depleted. Minimal natural resources such as soil and water and energy are depleted to grow, harvest, and transport the food. A sustainable diet contains foods that are produced in a way that is eco- logically neutral. Natural resources are used internally to produce foods and externally to move foods from producers to consumers. Buying locally grown food decreases the amount of fuel needed to transport food and is one way to reduce the use of external natural resources in food systems.

Farmers Markets 765

although adapting to eating seasonally can be an adjustment, it is more environ- mentally friendly because produce is not transported long distances for sale.

Farmers markets vary by what can be sold but generally a product must be grown or raised or made (baked, canned, and so on) by the farm selling it. “Local” is also usually understood to mean food that comes from independent farmers and producers rather than from large corporations.

Costs at farmers markets vary and sometimes produce may be more expensive than at a grocery store. Food bought in the conventional system where pesticides are used and the food is trans- ported thousands of miles and stored in warehouses is heavily subsidized at all stages of production and incurs costs not reflected in the purchase price. These costs include depleted fossil fuel reserves for fertilizer, cultivation, and transporta- tion; water pollution from pesticide runoff; and the contribution of emissions to global warming.

Some products sold at farmers mar- kets are certified organic, whereas others use integrated pest management (IPM) or use organic methods but are not USDA certified. Farmers sell directly to consum- ers for a number of reasons and those who do generally care for their land and use sustainable growing practices to keep it healthy.

Farmers markets are good for the local economy, the health of the land, and the health of the people. The USDA’s farmers market locator tells you where to find a farmers market near you: http://search. ams.usda.gov/farmersmarkets.

Reference 1. USDA. Agricultural Marketing Service. n.d.

Farmers Markets and Direct-to-Consumer Market- ing. Available at https://www.ams.usda.gov/ services/local-regional/farmers-markets- and-direct-consumer-marketing. Accessed April 2017.

and other parties interested in supporting direct farm marketing venues. Many farm- ers markets accept WIC (Women, Infants, and Children) vouchers and SNAP (Sup- plemental Nutrition Assistance Program) vouchers and provide nutrition education and food preparation demonstrations in conjunction with local and state health departments.

The USDA’s AMS has also formed the Farmers Market Consortium, which is a public-/private-sector partnership dedicated to helping farmers markets by sharing information about fund- ing and resources available to them. The consortium publishes the Farmers Market Resource Guide that provides a centralized repository of information about federal and private resources that support farmers markets. The USDA also publishes the National Farmers Market Directory that organizes farmers markets by state and includes contact information, dates, and times of operation.

Produce sold at farmers markets is available according to the season;

According to the USDA, farm-ers markets are an integral part of the urban–farm linkage and their growth has continued to rise. The number of farmers markets nation- wide has increased 2.3 percent, from 1,755 in 1994 to 8,669 in 2016.1 The USDA estimates that these markets generate approximately $1 billion in consumer spending each year. Most of this growth, a boon to local communi- ties’ economies, can be attributed to consumer interest in obtaining fresh products directly from the farm. In many cases consumers have the opportunity to personally interact with the farmer who grows the produce.

The USDA, in conjunction with the Agricultural Marketing Service (AMS), pro- vides technical support to managers of farmers markets by hosting conferences and training sessions throughout the country to present research findings and information on marketing strategies with agricultural producers, economists, state Department of Agriculture personnel,

Farmers MarketsSPOTLIGHT

Farmers markets provide fresh produce to the consumer.

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HEALTHCONNECTION

characteristics has become faster and more controlled. Today, scientists use biotech- nology to modify the genomes of plants and animals to create desired characteristics with great precision. American farmers routinely use selectively bred, genetically modified plants to create disease-resistant crops that produce larger, hardier fruits and vegetables and increase overall crop yields. The production of foods using plant or animal products that have been modified genetically helps to keep food costs low and availability high. In fact, the majority of fruits and vegetables on the market today are a product of genetic modification.141

Genetic Engineering Is the Latest Form of Biotechnology Genetic engineering (GE) allows scientists to alter the genetic makeup of an organism by manipulating DNA sequences. In genetic engineering, or bio- engineering, an exact gene or genes from the DNA sequence of an organism are isolated and inserted into the DNA of another species to create the genetically modified product (Figure 20.14).

This cutting and splicing of genes into the genome of another cell is called recom- binant DNA technology. Organisms that have

biotechnology Manipulation of living organisms or their components to develop or manufacture useful products.

genome Total genetic information of an organism stored in the DNA of its chromosomes.

genetic engineering (GE) Biological technique that isolates and manipulates the genes of organisms to produce a targeted, modified product.

been genetically engineered to contain both original and foreign genes are called geneti- cally modified organisms (GMOs). These GMOs are used to grow genetically engineered (GE) plants that produce GE foods.

Farmers in the United States have adopted GE crops widely since their introduction in 1996. Soybeans and cot- ton genetically engineered with herbicide- resistant traits have been the most widely accepted crops. According to the USDA’s National Agricultural Statistics Service (NASS), in 2013, 90 percent of the corn, 93 percent of the soybeans, and 90 percent of the cotton planted in the United States were genetically engineered varieties.142

Proponents Believe GMOs Can Increase the World’s Food Supply Many experts believe that GMOs are part of the solution to the problem of meeting the world population’s need for food with limited resources. GMOs have helped to increase the yield of crops in the United States and can do the same for developing countries that struggle to produce food.143 Genetic engineering may also create new uses for plants in industries such as phar- maceuticals and manufacturing.

genetically modified organisms (GMOs) Organisms that have been genetically engineered to contain both original and foreign genes.

Is Genetically Engineered Food Safe? LO 20.6 Compare the benefits and

risks of the use of biotechnology in our current food system.

Historically, farmers have crossbred plants by trial and error, crossing two plants to produce a hybrid offspring with the desired combination of characteristics. For example, if one tree produced large apples with thinner skins and another produced smaller, sour apples with thicker skins, an ancient apple farmer might have bred the two in the hope of producing a tree with large, fleshy, hardy fruit. This process is called cross-breeding. Today’s apples are an example of a plant food that has resulted from generations of deliber- ate cross-breeding.

For thousands of years, humans have cross-bred different versions of plants and animals to produce more desirable offspring. The offspring contain qualities from both parents, and it usually takes dozens of addi- tional crosses and many years to separate the desirable traits from the less desirable ones.

In the last century, as scientists have come to understand more about the work- ings of DNA and how to manipulate it, the process of cross-breeding for particular

cross-breeding Type of biotechnology in which two plants or two animals with different qualities are bred to produce offspring with desired traits from both.

The apples of today are larger and sweeter than their ancestors, thanks to hundreds of years of selective breeding.

HEALTHCONNECTION (CONTINUED)

Is Genetically Engineered Food Safe? 767

application of herbicide has led to the development of herbicide-resistant “super- weeds,” as discussed shortly. According to the USDA, approximately 93 percent of soybeans planted in 2013 were genetically modified to be herbicide resistant.147

The second generation of GE prod- ucts to hit the market was designed for increased shelf-life and improved nutri- ent composition.148 Tomatoes that stay firm and ripe longer were among the first genetically engineered foods to be sold to consumers. An example of a genetically altered plant with an improved nutrient profile is “golden rice.” In countries like Southeast Asia, India, and Africa rice is a staple of the diet. Golden rice has gene segments from a bacterium and a daffodil that instruct the rice plant cells to synthe- size beta-carotene and to concentrate the levels of iron (Figure 20.16). If success- fully cultivated by farmers and accepted

humans or animals. When the gene for this toxin is inserted into a crop plant, the plant becomes resistant to these pests.145 Some corn crops in the United States contain the Bt gene, which makes them resistant to some insect pests (Figure 20.15). Because chemical insecticides are not necessary, many benign insects are spared, and insect biodiversity is retained. Almost 15 percent

of corn and cotton har- vested in the United States in 2012 were varieties geneti- cally engineered to contain the Bt gene.146

Another goal of the first- generation GE products was to use this technology to improve a crop’s toler- ance to herbicides. With an herbicide-resistant version of a desired crop, a farmer can spray herbicide over a field to kill a variety of weeds without harming the crop. Unfortunately, this liberal

biodiversity Variability among living organisms on the earth, including the variability within and between species and within and between ecosystems.

The original purpose of GE plants was to reduce the amount of pesticides used on food crops by engineering the plants them- selves to be more resistant to pests. This would benefit both the health of consumers and the environment.144 For example, the bacterium Bacillus thuringiensis (Bt), which is found naturally in soil, produces a toxin that is poisonous to certain pests but not to

▲ Figure 20.14 Traditional Cross-Breeding versus Genetic Engineering

Donor DNA

Result

X (cross)

Desired gene

Recipient DNA

Desired gene

Undesired new DNA

Donor DNA

Result

Isolate gene

Desired gene

Recipient DNA

Desired gene

Traditional plant breeding involved crossing two plants of the same species to produce DNA with more desirable traits. The process was imprecise, however, and achieving the desired result could take years.

a Today, genetic engineering allows scientists to precisely manipulate the DNA from plants and impart desirable qualities from one plant to its offspring much more quickly.

b

▲ Figure 20.15 European Corn Borer Caterpillar Bt corn has been genetically engineered to produce a protein that is toxic to the larvae of the European corn borer, the most damaging insect pest of corn in North America.

▲ Figure 20.16 Genetically Engineered Golden Rice “Golden rice” is rich in both beta-carotene and iron and is a product of genetic engineer- ing. Because of agricultural and political chal- lenges, golden rice is not yet commercially available.

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HEALTHCONNECTION (CONTINUED)

Similarly, liberal application of herbicides on genetically engineered herbicide-resistant crops has fostered the development of superweeds throughout the United States and in 18 countries worldwide.160 Some experts predict that, as a direct result of the use of herbicide-resistant GM crops, the use of herbicides will more than double between 2013 and 2025.161

Other concerns have arisen about GMOs leading to the unintentional produc- tion of plant toxins, changes in the nutrient content and substances in foods, and the production of unsafe animal feed. Table 20.7 lists the regulations the FDA has put in place to address these issues.

GE Foods Are Highly Regulated in the United States Genetic engineering is tightly regulated in the United States. GE foods are regulated by the same three govern- ment agencies that regulate pesticides: the FDA, USDA, and EPA. The FDA ensures that GE foods are safe to eat and labeled if they contain a suspected aller- gen. The USDA ensures that the plants are safe to grow, while the EPA makes certain that the gene for any pesticide, such as that for Bt toxin, inserted into a plant is safe and won’t have adverse envi- ronmental effects. Though these agen- cies work together to ensure the safety of GE foods, the FDA has the overall authority to remove any GE food that doesn’t meet the same high safety stan- dards that are set for its conventionally grown equivalent.162

The FDA must review and approve all GE products before they are allowed on the market. As part of this process, the FDA mandates that the developers of GE foods conduct extensive tests to ensure their safety, then send the FDA a report of the findings. The FDA reviews the documentation and seeks additional information as warranted. Once all

Unintentional Transfer of Genes and Proteins Proteins from GM crops have been found in wild, non-GM crops several miles distant. Wind pollination and seed dispersal are mechanisms that can lead to this unintentional cross-breeding. Some of the proteins transferred to non-GM foods could be allergens.155 Under the FDA’s biotech policy, food companies must declare on food labels when a product includes a gene from one of the common allergy-causing foods, unless the company can show that the protein produced by the added gene does not cause allergies.156 The following eight foods account for 90 percent of all food allergies: milk, eggs, peanuts, tree nuts, fish, shellfish, soy, and wheat.157 The effects of introducing genes from allergenic foods into other products must be carefully assessed before these GM products are released for human consumption. Recently, GE salmon was approved by the FDA. This salmon grows twice as fast as wild salmon, and therefore has the potential to supply an increasingly demanding food market. The salmon are sterile and are confined to enclosures; however, if only a small percentage of the fish were not sterile and escaped into the wild, genes could be transferred from GE salmon to wild salmon.158

Disruption of Ecosystems and Development of Superweeds We noted above concerns that GMOs could lead to the disruption of ecosys- tems. A common example is the recent and dramatic decline (by about 80 percent between 2005 and 2015) in the popula- tion of monarch butterflies. Although climate change is almost certainly a fac- tor, depletion of milkweed (the monarch caterpillar’s food source) due to heavy application of powerful herbicides on herbicide-resistant GM crops is also thought to play a key role.159

by consumers, golden rice could help eliminate the epidemic of vitamin A and iron deficiency in Asia and worldwide.149 Although the beta-carotene from golden rice has been found to be bioavailable150

and despite decades of development, golden rice has yet to be distributed, as finding a strain productive enough for farms to grow successfully and gaining consumer acceptance have been chal- lenges. Another example of a genetically modified food with an improved nutrient profile is high-oleic-acid soybeans, which produce oil that is less prone to becoming rancid and thus is more stable when used for frying foods.

Genetic research has progressed to third-generation GE products that hold promise in the pharmaceutical, environ- mental, and industrial arenas. In fact, the first GE product created for commercial use was human insulin (needed by diabetics) produced by genetically engineered E. coli bacteria. Geneticists are currently exploring techniques for genetically engineering GI tract cells to produce insulin for patients with diabetes.151 Plants can also be geneti- cally modified to create substances with numerous medical uses, such as vaccines, antibiotics, anticlotting drugs, hormones, and substitutes for certain blood sub- stances.152 Scientists are currently experi- menting with the concept of “growing” vaccines for measles, hepatitis B, and noro- virus in produce.153

Some Consumers and Environmentalists Have Concerns about GMOs Some consumers and environmental- ists have concerns about the long-term effects of GMOs on human health and on the environment. These include the unintentional introduction of genes and proteins into non-GM foods, disruption of ecosystems, and introduction of her- bicide-resistant superweeds, as mentioned earlier.154

HEALTHCONNECTION (CONTINUED)

Is Genetically Engineered Food Safe? 769

FDA guidelines are satisfied, the food is considered safe and is allowed to enter the market. More than 50 GE foods, including canola oil, corn, cottonseed oil, potatoes, soybeans, squash, and toma- toes, have been evaluated by the FDA and are considered as safe as their con- ventional counterparts.163 The FDA has yet to approve any GE meat for human consumption, but as noted earlier has approved a GE salmon that grows faster than normal.164

Most consumers want genetically engi- neered foods to be labeled; however, the FDA has concluded that because there isn’t any scientific evidence that GE foods differ from their conventionally grown counter- parts, labeling isn’t warranted.165 The Amer- ican Medical Association and the Society of Toxicology share this position.166,167 Canada follows the United States in this regard. If a manufacturer chooses to voluntarily label a product, it may state that the product has been “genetically engineered.” Mandatory

Concern FDA Regulation

Undesirable genetic modification

To avoid the creation of undesirable products, all genes used must not have prior evidence of encoding any harmful substances. The genes must also be stably inserted into the plant in order to avoid any rearranging of genetic information that would produce an undesirable substance.

Introduction of allergens GE foods must be monitored for food allergens. Protein encoded from common allergen food sources (such as milk, eggs, fish, tree nuts, and legumes) should be presumed to be allergens and should be labeled as such on the GE food.

Excessive level of toxins GE foods should not contain natural toxins at levels that are higher than those found naturally in plants.

Changes in nutrients All GE foods should be monitored to assess unintentional changes in the nutrient levels in the plants and their ability to be utilized in the human body as compared with their conventional counterparts.

Creation of new substances

If the genes that are introduced into plants encode substances that are different in structure and function than those normally found in foods, these substances would need to be approved by the FDA, as would any other food additive. However, if these substances are GRAS or “substantially equivalent” to substances that already exist in foods, they do not need the FDA’s premarket approval.

Unsafe animal feeds Because a single plant type may be the predominant food source in an animal feed, all GE animal feeds must meet the same strict safety standards that are in place for food that is grown for humans.

Source: U.S. FDA. 2017. How FDA Regulates Food from Genetically Engineered Plants. Available at https://www.fda.gov/Food/IngredientsPackagingLabeling/GEPlants/ ucm461831.htmhtm. Accessed April 2017.

TABLE 20.7 Concerns and Regulations for GE Foods

labeling of GE foods is required in other countries across the world, including in the European Union, Japan, Australia, and New Zealand.168

Consumer acceptance of GE foods is increasing as a result of such foods becom- ing more common, their putative health benefits, and improved quality, but many consumers remain skeptical. In a recent survey, 88 percent of scientists but only 37 percent of the general public agreed that it

LO 20.6: THE TAKE-HOME MESSAGE Traditional cross-breeding and modern genetic engineering are types of biotechnology that alter an organism’s genetic makeup to create a new plant or animal with more desirable traits. Many GM crops, including corn, soybeans, and potatoes, are currently available in the United States and are commonly used as ingredients in processed foods. Genetically engineered crops can be developed to be pest resistant, to provide additional nutrients, and to enhance flavor and quality. GE products are heav- ily regulated to minimize undesirable genetic modifications, the introduction of potential allergens, and unfavorable nutrient changes in food. However, health and environmental concerns remain. Labeling is not currently mandatory for GE foods in the United States.

is generally safe to eat GE foods.169 Though many questions remain as to the long-term safety and impact of introducing GE foods into the world’s food supply, GMOs offer attractive options for feeding the world’s population now and in the future. An advanced technology of direct genome editing may permit modification without the use of recombinant DNA. This may increase the acceptance of GE foods in countries where they are poorly accepted.170

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Visual Chapter Summary

LO 20.1 Foodborne Illness Is Caused by  Pathogens and Toxins Pathogens (viruses, bacteria, molds, parasites, and prions) cause foodborne infection. Toxins produced by bacteria or present in food, either naturally or through chemical contamination, can cause foodborne intoxication. Norovirus is the single greatest cause of foodborne illness in the United States. The most common bacteria that cause foodborne illness are Salmonella, Clostridium perfringens, Campylo- bacter, and Staphylococcus aureus. Marine toxins and chemical contaminants, such as PCBs and methylmercury, can bioaccumu- late to toxic levels in large fish. Older adults, children, pregnant women, and people with certain disorders have compromised immunity and are at higher risk of contracting foodborne illness and suffering complications.

LO 20.2 Proper Food Handling Can Prevent Foodborne Illness Proper food-handling techniques during four critical steps—cleaning, combating cross-contamination, cooking, and chilling—can help reduce the risk of foodborne illness. Handwashing is the first step in avoiding foodborne illness. Foodborne bacte- ria multiply most rapidly in temperatures between 40° and 140°F (4.4–60°C), a range known as the danger zone. Cold foods should be stored and served below 40°F, and hot foods must be kept above 140°F. The only sure way to tell if a food has reached a safe temperature is to measure it using a kitchen thermometer. Extra caution is needed when traveling abroad, particularly in developing countries, to avoid foodborne illness. As a general guideline to avoid foodborne illness while traveling, do not eat raw produce unless you wash and peel it first, and avoid drinking tap water or using ice made from tap water unless the water is boiled or treated with iodine or chlorine first.

LO 20.3 Everyone Plays a Role in Protecting Our Food Supply Everyone, from the farmer to the con- sumer, plays an important role in food safety. Through the coordinated effort of the Food Safety Initiative, numerous U.S. government agencies work together to safeguard America’s food supply against foodborne illness. Hazard Analy- sis and Critical Control Point (HACCP) procedures are used by both the FDA and USDA to identify and control food- borne hazards that occur in all stages of the food system. Food manufacturers use techniques such as pasteurization, canning, and irradiation to help keep food safe for extended periods of time. Food irradiation exposes a food item to a radiant energy source that kills or greatly reduces some pathogens. Food product dating is not a measure of food safety, but can be used to determine peak qual- ity. The EPA monitors and regulates the safety of the water supply.

Visual Chapter Summary 771

LO 20.4 Food Additives and Other Chemicals Play a Role in Food Production and Safety Food additives are used as preservatives, antioxidants, flavoring, coloring, and leav- ening agents; to maintain a food’s consistency; and to add nutrients. Pesticides are substances that allow crops to flourish by killing or repelling damaging pests. Natu- ral biopesticides and antimicrobials are less toxic than chemical pesticides such as organophosphates. Integrated pest management (IPM) is used by many farmers and is designed to use the most economical methods to control pests with the least risk of harm to the consumer, the crops, and the environment. The FDA regulates the use of additives and, along with the EPA and USDA, regulates the use of pesticides. Growth hormones are sometimes provided to food-producing animals to increase the yield of product. The FDA regulates the administration of antibiotics to food animals. Foods with the USDA organic seal are grown without the use of most synthetic pesticides, synthetic fertilizers, bioengineering, or irradiation. Only antibiotic-free or growth hormone–free animals can be used to produce organic meat, poultry, eggs, and dairy foods.

Donor DNA

Result

Isolate gene

Desired gene

Recipient DNA

Desired gene

LO 20.5 A Sustainable Food System Conserves Natural Resources A sustainable food system is one that can be maintained indefinitely because it conserves and protects natural resources, empowers social responsibility, and is economically viable. Food systems are impacted by social, political, economic, and environmental factors and depend on human and natural resources. Soil, biodiversity, energy, and water are key natural resources that must be preserved. Buying locally grown food decreases the amount of fuel needed to transport food and is one way to reduce the use of external natu- ral resources in food systems.

LO 20.6 Biotechnology Is Used to Alter the Genetic Makeup of Foods Biotechnology, such as traditional cross- breeding and genetic engineering, is the application of biological techniques to alter the genetic makeup of living cells in order to produce organisms with a desired trait. Genetic engineering uses recombinant DNA technology to insert a gene or genes into the DNA of another cell to create a genetically modified prod- uct. Genetic engineering is conducted to improve crop yields, reduce the use of pesticides, and in some cases enhance the nutritional value of foods. Genetically engineered foods are heavily regulated in the United States, but some consum- ers and environmentalists are concerned about the long-term effects of these products. More and longer-term studies examining the effects of genetically engi- neered foods are needed.

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Terms to Know ■ food system ■ foodborne illness ■ pathogens ■ toxin ■ fecal-to-oral transmission ■ virus ■ host ■ norovirus ■ bacteria ■ hemolytic uremic syndrome ■ molds ■ parasites ■ prion ■ marine toxins ■ scombrotoxic fish poisoning ■ ciguatera poisoning ■ bioaccumulate ■ paralytic shellfish poisoning ■ solanine ■ polychlorinated biphenyls (PCBs) ■ cross-contaminate ■ myoglobin ■ danger zone

■ traveler’s diarrhea ■ farm-to-table continuum ■ Food Safety Initiative (FSI) ■ DNA fingerprinting ■ food preservation ■ pasteurization ■ canning ■ spores ■ modified atmosphere packaging

(MAP) ■ high-pressure processing (HPP) ■ irradiation ■ closed (or coded) dating ■ open dating ■ food additives ■ preservatives ■ nitrites and nitrates ■ sulfites ■ monosodium glutamate (MSG) ■ prior-sanctioned ■ generally recognized as safe (GRAS) ■ DeLaney Clause ■ intentional food additives ■ unintentional food additives ■ bovine growth hormone (BGH)

■ recombinant bovine somatotropin (rBST)

■ antibiotics ■ antibiotic-resistant bacteria ■ pesticides ■ herbicides ■ insecticides ■ antimicrobials ■ fungicides ■ rodenticides ■ organophosphates ■ risk assessment ■ acceptable tolerance levels ■ integrated pest management (IPM) ■ organic ■ sustainable ■ locavore ■ community-supported agriculture (CSA) ■ cross-breeding ■ biotechnology ■ genome ■ genetic engineering ■ genetically modified organisms

(GMOs) ■ biodiversity

Mastering Nutrition Visit the Study Area in Mastering Nutrition to hear an MP3 chapter summary.

Check Your Understanding LO 20.1 1. Which of the following

produce toxins that may cause foodborne illness? a. Parasites b. Viruses c. Bacteria d. Food additives

LO 20.1 2. Which of the following pathogens is the most common cause of foodborne infection in the United States? a. Clostridium botulinum b. norovirus c. Trichinella spiralis d. Escherichia coli O157:H7

LO 20.2 3. Which of the following sets of four steps is recommended by the Fight BAC! campaign? a. Cutting, cleaning, chopping,

and chilling b. Cleaning, combating cross-

contamination, cutting, and chilling

c. Clearing, combating cross- contamination, cutting, and chilling

d. Cleaning, combating cross- contamination, cooking, and chilling

LO 20.2 4. At what temperature, known as the danger zone, do bacteria readily thrive and multiply? a. Any temperature above 40°F b. Between 20° and 120°F c. Between 40° and 140°F d. Any temperature below

140°F

LO 20.3 5. Which two government agencies oversee the safety of the majority of foods in the United States? a. United States Department

of Agriculture (USDA) and Environmental Protection Agency (EPA)

b. Centers for Disease Control and Prevention (CDC) and USDA

c. USDA and Food and Drug Administration (FDA)

d. FDA and EPA LO 20.3 6. Which of the follow-

ing preservation techniques destroys specific foodborne pathogens by breaking up the cells’ DNA? a. Irradiation b. Pasteurization c. Canning d. High-pressure processing

Answers to True or False? 773

LO 20.4 7. Which of the following food additives is on the FDA’s GRAS list, is often added to enhance the flavor of savory foods, and causes adverse reactions among some individuals? a. Nitrites b. Sulfites c. Monosodium glutamate d. Vitamin E

LO 20.4 8. A frozen chicken enchilada that has the USDA Organic seal on its label means which of the following? a. One hundred percent of the

ingredients in the product are organic.

b. No pesticides were used to grow the corn from which the tortillas were made.

c. The chickens in the enchi- lada were grown without using antibiotics or growth hormones.

d. The organic enchilada is better for you because it is indisputably more nutrient- dense than a nonorganic chicken enchilada.

LO 20.5 9. Which of the following is a justified reason for buying food grown and produced locally? a. Locally grown food is more

nutrient dense than non– locally grown food.

b. Locally grown foods are organic foods.

c. Locally grown foods are free from pesticides.

d. Locally grown foods use fewer external natural resources than do non– locally grown foods.

LO 20.6 10. Which of the following is a key reason that consumers want genetically engineered (GE) foods labeled? a. GE foods can cause

cancer. b. GE foods are linked to

impaired cognitive growth in children.

c. GE foods are not regulated by the FDA.

d. GE foods may contain allergens.

Answers 1. (c) Bacteria are the only pathogens

that produce toxins and cause ill- ness due to foodborne intoxication. Some but not all parasites, viruses, and bacteria cause illness due to foodborne infection. Food additives are common in food and should not cause illness. Food additives are either approved by the FDA prior to their use or have GRAS or prior- sanctioned status based on a history of safe consumption.

2. (b) Half of all foodborne illness is caused by infection due to the noro- virus. Illnesses due to Clostridium botulinum, Trichinella spiralis, and Escherichia coli O157:H7 are much less common. Clostridium botulinum and Escherichia coli O157:H7 are spe- cies of bacteria that produce toxins. Trichinella spiralis is a parasite.

3. (d) To prevent foodborne illness, clean, combat cross-contamination, cook, and chill.

4. (c) Bacteria thrive and multiply best between the temperatures of 40° and 140°F. Below 40°F, bacterial repli- cation slows. Temperatures above 140°F destroy bacteria involved in foodborne illness.

5. (c) The USDA and FDA oversee the safety of most foods in the United States. Neither the CDC nor the EPA has direct regulatory oversight of the food supply.

6. (a) Irradiation involves using radia- tion to damage the DNA of patho- gens. Pasteurization and canning both use high temperatures to kill pathogens, while high-pressure processing employs pulses of high pressure.

7. (c) Monosodium glutamate is a flavor enhancer and has GRAS status, but some people may experience symp- toms such as numbness, a burning sensation, facial pressure or tight- ness, chest pain, and rapid heartbeat after consuming MSG. Nitrites and sulfites and vitamin E are additives that help preserve food.

8. (c) The USDA Organic seal indicates that 95 percent of the ingredients in a food are grown organically and that

food-producing animals used in the product were grown without the use of hormones or antibiotics. Some, but not all, pesticides may be used by organic farmers. There is little evi- dence that organically grown foods are more nutritious or safer for you than foods grown using conventional methods.

9. (d) Locally grown food requires fewer external natural resources in the form of fossil fuels from farm to your fork. However, just because a food is grown locally does not necessarily mean that it is grown organically, free from pesticides, or more nutrient dense than foods that are grown further from your home.

10. (d) Many consumers are concerned that GE foods may contain unin- tentional allergens. No evidence suggests that consumption of GE foods causes cancer. Lead exposure causes impaired cognitive growth in children. The USDA, EPA, and FDA regulate all GE foods.

Answers to True or False? 1. False. A food may contain disease-

causing bacteria or other contami- nants, yet look and smell perfectly fine.

2. False. Hand sanitizer kills most dis- ease-causing pathogens, as do soap and water. It is not necessary to wash your hands with soap and water if you use hand sanitizer.

3. True. A kitchen sponge provides the perfect medium for bacterial growth: moisture, nutrients, and room temperature.

4. False. Freezing doesn’t kill bacteria but puts them in a dormant state. Once thawed, some bacteria can continue to grow and reproduce.

5. False. Leftovers should be thrown out if they’re not consumed within 3–5 days.

6. False. Package dates refer to food quality, not safety.

7. False. The FDA deems food addi- tives safe if they present a “negligible risk” of cancer to human beings with lifetime use.

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8. False. A diet consisting only of locally grown foods might or might not be a sustainable diet because not all local farms guarantee that the foods were grown in a sustain- able way. A sustainable diet contains foods that meet your nutrient and health needs but can be produced for a long time without negatively affect- ing the environment.

9. False. Some synthetic pesticides have been approved for use on organic crops.

10. True. Corn, potatoes, and soybeans have been genetically modified to include a bacterial gene that makes them more resistant to insects since the 1990s. Labeling of genetically engineered foods is not mandatory in the United States, but many prod- ucts contain genetically modified ingredients.

Web Resources ■ For food safety education, visit

www.fightbac.org ■ For foodborne illness fact sheets, visit

https://www.fsis.usda.gov/wps/por- tal/fsis/topics/food-safety-education/ get-answers/food-safety-fact-sheets

■ For more information on organic foods, visit https://www.ams.usda. gov/about-ams/programs-offices/ national-organic-program

■ For information on biotechnology, visit https://www.fda.gov/food/ guidanceregulation/guidancedocu- mentsregulatoryinformation/biotech- nology/default.htm

References 1. Centers for Disease Control and Prevention.

2016. CDC Estimates of Foodborne Illness in the United States. Available at https://www.cdc .gov/foodborneburden/2011-foodborne- estimates.html. Accessed April 2017.

2. Ibid. 3. Centers for Disease Control and Prevention.

2016. Botulism. Available at https://www.cdc .gov/botulism/. Accessed April 2017.

4. U.S. Food and Drug Administration. 2015. Preventive Control Measures for Fresh & Fresh- Cut Produce: Chapter IV: Outbreaks Associated with Fresh and Fresh-Cut Produce. Incidence, Growth, and Survival of Pathogens in Fresh and Fresh-Cut Produce. Available at https:// www.fda.gov/Food/FoodScienceResearch/ ucm090977.htm. Accessed April 2017.

5. Centers for Disease Control and Preven- tion. 2016. Burden of Foodborne Illness: Findings. Available at https://www.cdc.gov/ foodborneburden/2011-foodborne- estimates.html. Accessed April 2017.

6. US Food and Drug Administration. 2016. Food Safety A to Z Reference Guide: Virus. Available at https://www.fda.gov/food/ foodscienceresearch/toolsmaterials/ ucm216150.htm. Accessed April 2017.

7. Ibid. 8. Shreiner, A. B., Kao, J. Y., and Young, V. B.

2015. The Gut Microbiome in Health and in Disease. Current Opinion in Gastroenterology 31(1):69–75.

9. DiBaise, J. K., Frank, D. N., and Mathur, R. 2012. Impact of the Gut Microbiota on the Development of Obesity: Current Concepts. American Journal of Gastroenterology Supplement 1:22–27.

10. Centers for Disease Control and Preven- tion. 2016. Burden of Foodborne Illness: Findings. Available at https://www.cdc.gov/ foodborneburden/2011-foodborne- estimates.html. Accessed April 2017.

11. Centers for Disease Control and Preven- tion. 2017. E. coli (Escherichia coli). Available at https://www.cdc.gov/ecoli/index.html. Accessed April 2017.

12. United States Department of Agriculture. 2013. Molds on Foods: Are They Dangerous? Available at 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. Accessed April 2017.

13. Food Safety and Inspection Service. 2013. Fact Sheet: Parasites and Foodborne Illness. Avail- able at https://www.fsis.usda.gov/wps/ portal/fsis/topics/food-safety-education/ get-answers/food-safety-fact-sheets/ foodborne-illness-and-disease/parasites- and-foodborne-illness/ct_index. Accessed April 2017.

14. Cody, M.M. and Stretch, T. 2014 Posi- tion of the Academy of Nutrition and Dietetics: Food and Water Safety. Journal of the Academy of Nutrition and Dietetics 114(11):1819–1829.

15. U.S. Department of Agriculture. 2016. About BSE. Available at https://www.aphis .usda.gov/aphis/ourfocus/animalhealth/ animal-disease-information/cattle-disease- information/sa_bse/ct_about_bse. Accessed April 2017.

16. Centers for Disease Control and Preven- tion. 2015. BSE (Bovine Spongiform Encephalop- athy, or Mad Cow Disease): News and Highlights. Available at https://www.cdc.gov/prions/ bse/news.html. Accessed April 2017.

17. USDA. 2012. Statement by USDA Chief Veteri- nary Officer John Clifford Regarding a Detection of Bovine Spongiform Encephalopathy (BSE) in the United States. Release No. 0132.12, April 24, 2012. Available at https://www.usda.gov/ media/press-releases/2012/04/24/state- ment-usda-chief-veterinary-officer-john- clifford-regarding. Accessed April 2017.

18. United States Department of Agriculture. 2013. Statement from Agriculture Secretary Tom Vilsack Regarding World Organization for Animal Health (OIE) Upgrade of United States’ BSE Risk Status. Statement Release no. 0106.13. Available at https://www.usda. gov/media/press-releases/2013/05/29/ statement-agriculture-secretary-tom-vilsack- regarding-world. Accessed April 2017.

19. Centers for Disease Control and Preven- tion. 2016. Harmful Algal Bloom (HAB)- Associated Illness. Available at https://www. cdc.gov/habs/illness-symptoms-marine. html. Accessed April 2017.

20. Ibid. 21. Ibid. 22. Ibid. 23. Dolan, L. C., Matulka, R. A., Burdock, G.

A. 2010. Naturally Occurring Food Toxins. Toxins (Basel) 2(9):2289–2332. doi: 10.3390/ toxins2092289.

24. U.S. Environmental Protection Agency. 2017. Polychlorinated Biphenyls (PCBs). Avail- able at https://www.epa.gov/pcbs/learn- about-polychlorinated-biphenyls-pcbs. Accessed April 2017.

25. Agency for Toxic Substances and Disease Registry. 2014. ToxFAQs™ for Polychlorinated Biphenyls (PCBs). Available at https://www.atsdr.cdc.gov/toxfaqs/ tf.asp?id=140&tid=26 Accessed April 2017

26. U.S. Environmental Protection Agency. 2017. Polychlorinated Biphenyls (PCBs). Avail- able at https://www.epa.gov/pcbs/learn- about-polychlorinated-biphenyls-pcbs. Accessed April 2017.

27. Ibid. 28. Environmental Protection Agency. 2017.

Consumer Fact Sheet on PCBs. Available at https://www.epa.gov/environmental- topics/water-topics Accessed July 2017.

29. Rice, K. M., E. M. Walker, Jr., M. Wu, C. Gillette, and E. R. Blough. 2014. Environmen- tal Mercury and Its Toxic Effects. Journal of Pre- ventative Medicine and Public Health 47(2):74–83.

30. Environmental Protection Agency. 2017. Guidelines for Eating Fish that Contain Mer- cury. Available at https://www.epa.gov/ mercury/guidelines-eating-fish-contain- mercuryAccessed April 2017.

31. Food Safety.gov. 2017. Food Safety for Older Adults. Available at https://www.foodsafety.gov/risk/ olderadults/. Accessed April 2017.

32. U.S. Department of Health and Human Services, Administration on Aging. 2016. A Profile of Older Americans 2016. Available at https://aoa.acl.gov/aging_statistics/pro- file/index.aspx Accessed April 2017.

33. Cody, M. M., and Stretch, T. 2014. Position of the Academy of Nutrition and Dietetics: Food and Water Safety.

34. United States Department of Agriculture Food Safety and Inspection Service. 2017. Fact Sheets: Safe Food Handling. Available at https://www.fsis.usda.gov/wps/portal/ fsis/topics/food-safety-education/get- answers/food-safety-fact-sheets/safe-food- handling. Accessed April 2017.

References 775

35. US Food and Drug Administration. 2016. Science and Our Food Supply: Free Supplementary Curriculum for Middle Level and High School Class- rooms. Available at https://www.fda.gov/ food/foodscienceresearch/toolsmaterials/ scienceandthefoodsupply/default.htm. Accessed April 2017.

36. Partnership for Food Safety Education. 2017. Food Safety Basics: The Core Four Prac- tices. Available at http://www.fightbac.org/ food-safety-basics/the-core-four-practices/ Accessed April 2017.

37. US Food and Drug Administration. 2016. Food Safety A to Z Reference Guide: Handwash- ing. Available at https://www.fda.gov/ food/foodscienceresearch/toolsmaterials/ ucm216150.htm. Accessed April 2017.

38. CDC. 2016. Handwashing: Clean Hands Save Lives. Available at www.cdc.gov/handwash- ing. Accessed May 2017.

39. Ibid 40. Ibid 41. Academy of Nutrition and Dietetics. 2015.

The Do’s and Don’ts of Kitchen Sponge Safety. Available at http://www.eatright.org/ resource/homefoodsafety/four-steps/ wash/dos-and-donts-of-kitchen-sponge- safety Accessed May 2017.

42. Ibid. 43. Sorheim O., Hoy, M. 2013. Effects of food

ingredients and oxygen exposure on prema- ture browning in cooked beef. Meat Science 93(1):105–110.

44. US Department of Agriculture. Food Safety and Inspection Service. Modified August 2013. The Color of Meat and Poultry. Available at https://www.fsis.usda.gov/ wps/portal/fsis/topics/food-safety-educa- tion/get-answers/food-safety-fact-sheets/ meat-preparation/the-color-of-meat-and- poultry/the-color-of-meat-and-poultry/ ct_index. Accessed April 2017.

45. Food and Drug Administration. 2013. Food Code 2013. Available at https://www.fda.gov/ Food/GuidanceRegulation/RetailFoodPro- tection/FoodCode/ucm374275.htmww. fda.gov/Food/FoodSafety/RetailFoodPro- tection/FoodCode/default.htm. Accessed April 2017.

46. Food Safety and Inspection Service. Modi- fied June 2013. How Temperatures Affect Food. Available at https://www.fsis.usda.gov/ wps/portal/fsis/topics/food-safety-educa- tion/get-answers/food-safety-fact-sheets/ safe-food-handling/how-temperatures- affect-food/ct_indexAccessed April 2017.

47. Ibid. 48. Centers for Disease Control and Preven-

tion. 2013 Travelers’ Diarrhea. https:// wwwnc.cdc.gov/travel/page/travelers- diarrhea. Accessed April 2017.

49. Centers for Disease Control and Prevention. 2015. Travelers’ Health: Food and Water Safety. Available at https://wwwnc.cdc.gov/travel/ page/food-water-safety. Accessed April 2017.

50. Food and Drug Administration and U.S. Department of Agriculture. 2000. A Description of the U.S. Food Safety System.

Available at www.fsis.usda.gov/OA/codex/ system.htm. Accessed April 2017.

51. U.S. Food and Drug Administration. 2014. Congressional Testimony: Ensuring Food Safety: Tracking and Resolving the E.coli Spinach Out- break. Available at https://www.fda.gov/ NewsEvents/Testimony/ucm110926.htm. Accessed April 2017.

52. Centers for Disease Control and Preven- tion. 2006. Press Release: Multistate Outbreak of E. coli O157:H7 Infections Linked to Fresh Spinach. Available at https://www.cdc. gov/ecoli/2006/spinach-10-2006.html. Accessed April 2017.

53. US Food and Drug Administration. 2017. Hazard Analysis Critical Control Point (HACCP). Available at https://www.fda. gov/food/guidanceregulation/haccp/. Accessed April 2017.

54. Food and Drug Administration. 2013. Food Code 2013. Available at https://www.fda.gov/ Food/GuidanceRegulation/RetailFood- Protection/FoodCode/ucm374275.htmww. fda.gov/Food/FoodSafety/RetailFoodPro- tection/FoodCode/default.htm. Accessed April 2017.

55. US Food and Drug Administration. 2015. Talking about Juice Safety: What You Need to Know. Available at https://www.fda. gov/food/resourcesforyou/consumers/ ucm110526.htm. Accessed April 2017.

56. FoodReference.com. n.d. The History of Food Canning: About Canned Food and Whence It Came. Available at www.foodrefer- ence.com/html/artcanninghistory.html. Accessed April 2017.

57. Centers for Disease Control and Preven- tion. 2016. Botulism. Available at https:// www.cdc.gov/botulism/. Accessed April 2017.

58. Ibid. 59. Center for Food Safety and Applied Nutri-

tion. 2015. Analysis and Evaluation of Preventive Control Measures for the Control and Reduction/ Elimination of Microbial Hazards on Fresh and Fresh-Cut Produce. Available at https:// www.fda.gov/Food/FoodScienceResearch/ ucm090977.htm. Accessed April 2017.

60. Finley, J., D. Deming, and R. Smith. 2006. Food Processing: Nutrition, Safety, and Quality. In Shils, M., M. Shike, A. Ross, B. Caballero, and R. Cousins, eds. Modern Nutrition in Health and Disease. 10th ed. Philadelphia: Lippincott Williams & Wilkins.

61. Food and Drug Administration. 2016. Food Irradiation: What You Need to Know. Available at https://www.fda.gov/food/resources- foryou/consumers/ucm261680.htm. Accessed April 2017.

62. Kindu, D., A. Gill, and R. Holley. 2013. Use of Low-Dose Irradiation to Evaluate the Radiation Sensitivity of Escherichia coli O157:H7, non-O157 Verotoxigenic Esch- erichia coli, and Salmonella in Phosphate- Buffered Saline. Journal of Food Protection 76(8):1438–1442.

63. Food and Drug Administration. 2016. Food Irradiation: What You Need to Know.

64. Ibid.

65. Ibid. 66. Ibid. 67. Ibid. 68. Ibid. 69. Food Safety and Inspection Service. 2016.

Food Product Dating. U.S. Department of Agriculture. www.fsis.usda.gov. Accessed May 2017.

70. Ibid. 71. Environmental Protection Agency. 2017.

Safe Drinking Water Act: Consumer Confi- dence Reports (CCR). Available at https:// www.epa.gov/ccr Accessed April 2017.

72. Environmental Protection Agency. 2017. Learn About Lead. Available at https:// www.epa.gov/lead/learn-about-lead#lead. Accessed April 2017.

73. Cody, M. M., and Stretch, T. 2014. Position of the Academy of Nutrition and Dietetics: Food and Water Safety.

74. Centers for Disease Control and Preven- tion (CDC). 2012. Vital Signs: Food Cat- egories Contributing the Most to Sodium Consumption’ United States, 2007–2008. Morbidity and Mortality Weekly Report 6:62–98.

75. Bouvard, V., Loomis, D., Guyton, K. Z., Grosse, Y., Ghissassi, F. E., Benbrahim- Tallaa, L. Guha, N., Mattock, H., Straif, K., on behalf of the International Agency for Research on Cancer Monograph Working Group. 2015. Carcinogenicity of consump- tion of red and processed meat. Lancet Oncology 16(16):1599–1600.

76. National Toxicology Program. 2011. NTP 12th Report on Carcinogens. Report on Car- cinogens: Carcinogen Profiles iii–449.

77. FDA. 2014. Food Additives Status List. Available at https://www.fda.gov/food/ ingredientspackaginglabeling/foodaddi- tivesingredients/ucm091048.htm. Accessed April 2017.

78. Ibid. 79. Ibid. 80. FDA. 2014. Questions and Answers on Monoso-

dium Glutamate (MSG). Available at https:// www.fda.gov/food/ingredientspackag- inglabeling/foodadditivesingredients/ ucm328728.htm Accessed April 2017.

81. FDA. 2014. Food Additives Status List. Available at https://www.fda.gov/food/ingredientspack- aginglabeling/foodadditivesingredients/ ucm091048.htm Accessed April 2017.

82. FDA. 2017. Generally Recognized as Safe (GRAS). Available at https://www.fda.gov/ food/ingredientspackaginglabeling/gras/ Accessed April 2017.

83. FDA. 2014. Food Additives Status List. 84. Food and Drug Administration. Modified

2017. Questions and Answers about Dioxins and Food Safety. Available at https:// www.fsis.usda.gov/wps/wcm/connect/ fsis-content/internet/main/topics/data- collection-and-reports/chemistry/dioxin- related-activites Accessed April 2017.

85. Food and Drug Administration. Modi- fied 2014. Report on the Food and Drug Administration’s Review of the Safety of Recombinant Bovine Somatotropin. Available at

776 Chapter 20 | Food Safety, Technology, and Sustainability

https://www.fda.gov/animalveterinary/ safetyhealth/productsafetyinformation/ ucm130321.htm. Accessed April 2017.

86. American Cancer Society. 2014. Learn About Cancer: Recombinant Bovine Growth Hormone. Available at https://www.cancer.org/ cancer/cancer-causes/recombinant-bovine- growth-hormone.html. Accessed April 2017.

87. Food and Drug Administration. 2015. Steroid Hormone Implants Used for Growth in Food-Producing Animals. Available at https://www.fda.gov/animalveterinary/ safetyhealth/productsafetyinformation/ ucm055436.htm Accessed April 2017.

88. Ibid. 89. Centers for Disease Control and Preven-

tion, National Antimicrobial Resistance Monitoring System. Updated 2016. Antibi- otic Use in Food-Producing Animals: Tracking and Reducing the Public Health Impact. Avail- able at https://www.cdc.gov/narms/faq. html. Accessed April 2017.

90. Iovine, N. M., and M. J. Blaser. 2004. Anti- biotics in Animal Feed and Spread of Resis- tant Campylobacter from Poultry to Humans. Emerging Infectious Diseases 10(6):1158–1189. doi: 10.3201/eid1006.040403.

91. U.S. FDA. 2015. Veterinary Feed Directive. Available at https:// www.federalregister.gov/docu- ments/2015/06/03/2015-13393/veteri- nary-feed-directive. Accessed April 2017.

92. USDA. Modified 2015. Meat and Poultry Labeling Terms. https://www.fsis.usda.gov/ wps/portal/fsis/topics/food-safety-educa- tion/get-answers/food-safety-fact-sheets/ food-labeling/meat-and-poultry-labeling- terms. Accessed April 2017.

93. U.S. Environmental Protection Agency. 2017. Food and Pesticides. Available at https://www.epa.gov/safepestcontrol/ food-and-pesticides. Accessed May 2017.

94. U.S. Environmental Protection Agency. n.d. Pesticides. Available at https://www.epa.gov/ pesticides. Accessed April 2017

95. Ibid. 96. U.S. Environmental Protection Agency.

2017. What are Antimicrobial Pesticides. Avail- able at https://www.epa.gov/pesticide-reg- istration/what-are-antimicrobial-pesticides. Accessed April 2017

97. Food and Drug Administration. 2014. FDA Fact Sheet on Hand Hygiene in Retail and Food Service Establishments. Available at https://www.fda.gov/food/guidanceregu- lation/retailfoodprotection/industryand- regulatoryassistanceandtrainingresources/ ucm135577.htm. Accessed April 2017.

98. U.S. Environmental Protection Agency. 2017. Cumulative Assessment from Risk of Pes- ticides. Available at https://www.epa.gov/ pesticide-science-and-assessing-pesticide- risks/cumulative-assessment-risk-pesticides. Accessed May 2017.

99. U.S. Environmental Protection Agency. 2017. Pesticides Available at https://www. epa.gov/pesticides. Accessed April 2017.

100. Office of Disease Prevention and Health Promotion. U.S. Department of Health and Human Services. 2017. Healthy People 2020: Environmental Health Objectives. Available at https://www.healthypeople.gov/2020/top- ics-objectives/topic/environmental-health/ objectives. Accessed April 2017.

101. American Academy of Pediatrics. 2012. Policy Statement on Pesticide Exposure in Children. Pediatrics 130(6):e1757–e1763.

102. U.S. Environmental Protection Agency. 2017. Pesticides: Risk Assessment. Available at https:// www.epa.gov/pesticide-science-and-assess- ing-pesticide-risks/overview-risk-assessment- pesticide-program. Accessed April 2017.

103. U.S. Environmental Protection Agency. 2017. Pesticides: Pesticide Registration. Available at https://www.epa.gov/pesticide-registra- tion/about-pesticide-registration. Accessed April 2017.

104. U.S. Environmental Protection Agency. 2012. Pesticides and Food: How the Government

105. U.S. Environmental Protection Agency. 2016. Pesticides: Topical and Chemical Fact Sheets’ Integrated Pest Management (IPM) Prin- ciples. Available at https://www.epa.gov/ safepestcontrol/integrated-pest-manage- ment-ipm-principles. Accessed April 2017.

106. Ibid. 107. Food and Drug Administration. 2017. Pes-

ticides. Available at https://www.fda.gov/ food/foodborneillnesscontaminants/pesti- cides/. Accessed April 2017.

108. American Cancer Society. 2016. Common Questions About Diet and Cancer. Available at www.cancer.org. Accessed May 2017.

109. United States Department of Agriculture. 2017. National Organic Program. Available at www.ams.usda.gov/AMSv1.0/nop. Accessed April 2017.

110. Ibid. 111. Organic Trade Association. 2016. U.S.

Organic Industry Survey. Available at https:// www.ota.com/news/press-releases/19031. Accessed May 2017.

112. Ibid. 113. International Food Information Council.

2003. USDA Launches Organic Standards. Available athttp://www.foodinsight.org/ Portals/0/pdf/May-June-2003-PDF.pdf. Accessed April 2017.

114. Agricultural Marketing Service, National Organic Program. Revised 2016. National Organic Program Handbook: Guidance and Instructions for Accredited Certifying Agents and Certified Operations. https://www.ams.usda. gov/rules-regulations/organic/handbook/. Accessed April 2017.

115. Electronic Code of Federal Regula- tions. 2014. Title 7: Agriculture, Part 205’ National Organic Program, Subpart G’ Administrative: National List of Allowed and Prohibited Substances. Available at https://www.federalregister.gov/ documents/2014/09/30/2014-23135/ national-organic-program-nop-amend- ments-to-the-national-list-of-allowed-and- prohibited-substances. Accessed April 2017.

116. Bara?ski, M., Srednicka-Tober, D., Volaka- kis, N., Seal, C., Sanderson, R., Stewart G. B., Benbrook, C., Biavati, B., Markellou, E., Giotis, C., Gromadzka-Ostrowska, J., Rembia?kowska, E., Skwar?o-So?ta, K., Tahvonen, R., Janovská, D., Nig- gli, U., Nicot, P., and Leifert, C. 2014. Higher Antioxidant and Lower Cadmium Concentrations and Lower Incidence of Pesticide Residues in Organically Grown Crops: A Systematic Literature Review and Meta-analyses. British Journal of Nutrition 112(15):794–811. doi: 10.1017/ S0007114514001366.

117. Smith-Spangler, C., M. L. Brandeau, G. E. Hunter, J. C. Bavinger, M. Pearson, P. J. Eschbach, V. Sundaram, et al. 2012. Are Organic Foods Safer or Healthier than Conventional Alternatives?: A Sys- tematic Review. Annals of Internal Medicine 157(5):348–366.

118. Ibid. 119. United Nations, Department of Economic

and Social Affairs, Population Division. 2015. Population Trends. Available at http:// www.un.org/en/development/desa/popu- lation/theme/trends/. Accessed April 2017.

120. Tagtow, A., K. Robien, E. Bergquist, M. Mruening, L. Dierks, B. E. Hartman, et al. 2014. Academy of Nutrition and Dietetics: Standards of Professional Performance for Registered Dietitian Nutritionists (Compe- tent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Sys- tems. Journal of the Academy of Nutrition and Dietetics 114(3):475–488.

121. Center for Sustainable Food Systems, Uni- versity of Michigan. 2016. U.S. Food System Factsheet. Pub. No. CSS01-06. Available at http://css.snre.umich.edu/sites/default/ files/U.S._Food_System_Factsheet_CSS01- 06.pdf. Accessed May 2017.

122. USDA National Resources Conserva- tion Service. 2017. Soil Health. Available at https://www.nrcs.usda.gov/wps/ portal/nrcs/main/national/soils/health/. Accessed April 2017.

123. Tagtow, A., and Harmon A. 2009. Healthy Land, Healthy Food and Healthy Eaters. Dieti- cians Cultivating Sustainable Food Systems. Avail- able at www.uwyo.edu/winwyoming/pubs/ healthyland%20healthyfood%20healthyeat- ers.pdf. Accessed April 2017.

124. USDA Economic Research Service. 2017. Soil Tillage and Crop Rotation. Available at https://www.ers.usda.gov/topics/farm- practices-management/crop-livestock- practices/soil-tillage-and-crop-rotation/. Accessed May 2017.

125. United States Department of Agriculture. 2012. Colony Collapse Disorder Progress Report. Available at https://www.ars.usda.gov/ is/br/ccd/ccdprogressreport2012.pdf. Accessed April 2017.

126. Allendorf, F. W., O. Berry, and N. Ryman. 2014. So Long to Genetic Diversity, and Thanks For All the Fish. Molecular Ecology 23(1):23–25. doi: 10.1111/mec.12574.

References 777

127. Center for Sustainable Food Systems, Uni- versity of Michigan. 2016. U.S. Food System Factsheet. Pub. No. CSS01-06. Available at http://css.snre.umich.edu/sites/default/ files/U.S._Food_System_Factsheet_CSS01- 06.pdf Accessed May 2017.

128. Herrero, M., Havlik, P., Valin, H., Noten- baert, A., Rufino, M.C., Thornton, P.K., Blummel, M., Weiss, F., Grace, D., and Obersteiner, M. 2013. Biomass Use, Pro- duction, Feed Efficiencies, and Greenhouse Gas Emissions from Global Livestock Systems. Proceedings of the National Academy of Sciences of the United States of America 110(52):20888–20893. doi: 10.1073/ pnas.1308149110.

129. Beef Cattle Research Council. 2014. How Much Feed and Water are Used to Make a Pound of Beef? Available at www.beef- research.ca/blog/cattle-feed-water-use/. Accessed May 2017.

130. Center for Sustainable Food Systems, Uni- versity of Michigan. 2016. U.S. Food System Factsheet. Pub. No. CSS01-06. Available at http://css.snre.umich.edu/sites/default/ files/U.S._Food_System_Factsheet_CSS01- 06.pdf. Accessed May 2017.

131. Harmon, A. H., and B. L. Gerald. 2007. Position of the American Dietetic Associa- tion: Food and Nutrition Professionals Can Implement Practices to Conserve Natural Resources and Support Ecological Sustain- ability. Journal of the American Dietetic Associa- tion 107(6):1033–1043.

132. Environmental Protection Agency. 2017. Watersense. Available at https://www.epa.gov/ watersense/about-watersense Accessed April 2017.

133. Ibid. 134. Ibid. 135. Ibid. 136. National Oceanic and Atmospheric Admin-

istration, National Centers for Environ- mental Information. Global Climate Change Indicators. Available at https://www.ncdc. noaa.gov/monitoring-references/faq/indi- cators.php. Accessed May 2017.

137. USDA Economic Research Service. ERS Report Summary. 2016. Food Prices and Spending. Available at https://www.ers.usda. gov/data-products/ag-and-food-statistics- charting-the-essentials/food-prices-and- spending/. Accessed April 2017.

138. Harmon, A. H., and B. L. Gerald. 2007. Position of the American Dietetic Associa- tion: Food and Nutrition Professionals Can Implement Practices to Conserve Natural Resources and Support Ecological Sustain- ability. Journal of the American Dietetic Associa- tion 107(6):1033–1043.

139. United States Department of Agriculture. 2017. Know Your Farmer, Know Your Food. Available at https://www.cnpp.usda.gov/ KnowYourFarmer. Accessed April 2017.

140. Tagtow, A., et al. 2014. Academy of Nutri- tion and Dietetics: Standards of Profes- sional Performance for Registered Dietitian Nutritionists (Competent, Proficient,

and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems.

141. United States Department of Agriculture. Modified 2013. Biotechnology Frequently Asked Questions (FAQs). Available at https:// www.usda.gov/topics/biotechnology/ biotechnology-frequently-asked-questions- faqs. Accessed April 2017.

142. Economic Research Service. 2016. Adoption of Genetically Engineered Crops in the U.S. Available at https://www.ers.usda.gov/data-products/ adoption-of-genetically-engineered-crops-in- the-us.aspx. Accessed April 2017.

143. Quaim, M., Kouser, S. 2013. Genetically Modified Crops and Food Security. PLoS One 8(6):e64879. doi: 10.1371/journal. pone.0064879

144. USDA Economic Research Service. 2016. Adoption of Genetically Engineered Crops in the U.S. Available at https://www.ers. usda.gov/data-products/adoption-of- genetically-engineered-crops-in-the-us.aspx Accessed May 2017.

145. Ibid. 146. Economic Research Service. 2016. Adop-

tion of Genetically Engineered Crops in the U.S. Available at https://www.ers.usda.gov/ data-products/adoption-of-genetically- engineered-crops-in-the-us.aspx.

147. Economic Research Service. Updated 2016. Adoption of Genetically Engineered Crops in the U.S. Available at https://www. ers.usda.gov/data-products/adoption-of- genetically-engineered-crops-in-the-us. aspx. Accessed April 2017.

148. Ibid. 149. Bren, L. 2003. Genetic Engineering: The

Future of Foods. FDA Consumer 37:28–34. 150. Tang, G., Hu Y., Yin, S., Wang, Y., Dallal, G.

E., Grusak, M. A., and Russel, R. M. 2012. Beta Carotene in Golden Rice is as good as Beta carotene in oil at providing vitamin A to children. Golden Rice. American Journal of Clinical Nutrition 96:658–664.

151. Kieffer, T. J., and Seino, Y. 2016. Engineer- ing the gut for insulin replacement to treat diabetes. Journal of Diabetes Investigation 7(Suppl. 1): 87–93. doi: 10.1111/jdi.12479.

152. Peplow, M. 2016. Synthetic Biology’s First Malaria Drug Meets Market Resistance. Nature. Available at www.nature.com/ news/synthetic-biology-s-first-malaria- drug-meets-market-resistance-1.19426. Accessed May 2017.

153. Ibid. 154. Kramkowska, M., T. Grzelak, and K.

Czy?ewska. 2013. Benefits and Risks Associated with Genetically Modified Food Products. Annals of Agricultural and Environmental Medicine 20(3):413–419.

155. Buiatti, M, Christou, P., and Pastore, G. 2012. The Application of GMOs in Agri- culture and in Food Production for a Better Nutrition: Two Different Scientific Points of View. Genes and Nutrition 8(3):255–270. doi: 10.1007/s12263-012-0316-4

156. Food and Drug Administration. 2017. Bio- technology: Genetically Engineered Plants for Food

and Feed. Available at https://www.fda.gov/ Food/IngredientsPackagingLabeling/ GEPlants/default.htm. Accessed April 2017.

157. U.S. Food and Drug Administration. 2012. Have Food Allergies?: Read the Label. Avail- able at https://www.fda.gov/forconsum- ers/consumerupdates/ucm254504.htm. Accessed April 2017.

158. Ledford, H. 2016. Transgenic Salmon Nears Approval. Nature. Available at https://www.nature.com/news/transgenic- salmon-nears-approval-1.12903. Accessed May 2017.

159. Semmens, B. X, et al. 2016. Quasi-Extenic- tion Risk and Population Targets for the Eastern, Migratory Population of Monarch Butterflies. Scientific Reports 6, Article No. 23264. doi: 10.1038/srep23265.

160. Gilbert, G. 2013. A Hard Look at GM Crops. Nature 497:24–26.

161. Ibid. 162. Food and Drug Administration. 2015. Ques-

tions and Answers on Food from Genetically Engi- neered Plants. Available at www.fda.gov/food/ ingredientspackaginglabeling/geplants/ ucm346030.htm. Accessed April 2017.

163. U.S. Food and Drug Administration. 2017. Food from Genetically Engineered Plants. Available at https://www.fda.gov/Food/ IngredientsPackagingLabeling/GEPlants/ default.htm. Accessed April 2017.

164. Reuters. 2014. USDA Is Still Weigh- ing If Genetically Modified Salmon Is Safe to Eat. Available at www.reuters.com/ article/2014/03/13/us-usa-health-salmon- fda-idUSBREA2C23L20140313. Accessed April 2017.

165. Food and Drug Administration. 2015. Questions and Answers on Food from Genetically Engineered Plants.

166. American Medical Association. 2012. Policy H-480.958 Bioengineered (Geneti- cally Engineered )Crops and Foods. Avail- able at https://searchpf.ama-assn. org/SearchML/searchDetails. action?uri=%2FAMADoc%2FHOD.xml- 0-4359.xml. Accessed April 2017.

167. Society of Toxicology. 2003. The Safety of Genetically Modified Foods Produced through Biotechnology. Toxicological Sciences 71:2–8.

168. Center for Food Safety. 2014. Genetically Engineered Foods Labeling Laws. Available at www.centerforfoodsafety.org/ge-map. Accessed April 2017.

169. Pew Research Center. 2015. Chapter 3: Atti- tudes and Beliefs on Science and Technol- ogy Topics. Available at www.pewinternet. org/2015/01/29/chapter-3-attitudes-and- beliefs-on-science-and-technology-topics/. Accessed May 2017.

170. Kamthan, A., Chaudhuri, A., Kamthan, M., and Datta, A. 2016. Genetically Modi- fied (GM) Crops: Milestones and New Advances in Crop Improvement. Theoretical and Applied Genetics 129(9):1639–1655. doi: 10.1007/s00122-016-2747-6.

779

21 Learning Outcomes After reading this chapter, you will be able to:

21.1 Discuss the extent of food insecurity in the United States and the contributing factors.

21.2 Describe the causes of malnutrition worldwide.

21.3 Identify populations that are at greatest risk for malnutrition.

21.4 Explain several ways to reduce hunger.

21.5 Describe the health consequences of undernutrition.

True or False? 1. Malnutrition exists in every country in the world—including the United States. T/F

2. More than one-tenth of the world’s population does not have enough to eat. T/F

3. If you have a job, you will never experience food insecurity. T/F

4. Depression among mothers has been associated with food insecurity. T/F 5. Farmers grow enough food to feed

everyone on the planet today. T/F 6. Earthquakes can cause food shortages. T/F

7. Once you reach a certain age, you don’t need to worry about malnutrition. T/F 8. Fortifying foods is a good idea, but it doesn’t really affect malnutrition. T/F 9. You can’t be obese and food insecure at the same time. T/F

10. Iodine deficiency is the world’s most prevalent, yet easily preventable, cause of brain damage in children. T/F See page 798 for the answers.

Global Nutrition and Malnutrition

780 Chapter 21 | Global Nutrition and Malnutrition

What Factors Contribute to Malnutrition in the United States? LO 21.1 Discuss the extent of food insecurity in the United States and the contributing factors.

The United States is a developed country, one of the wealthiest in the world,4 yet many Americans cannot afford to buy adequate amounts of nourishing foods at a grocery store or dine out at a local restaurant. Hunger and malnutrition are very real problems across the United States, in inner cities, the suburbs, and in rural areas, and food insecurity is a large part of the problem.

Food Insecurity in the United States Is Significant The Economic Research Service (ERS) of the United States Department of Agriculture (USDA) uses four categories to identify different levels of food security in the United States (Table 21.1).5 Food insecurity describes “limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways.”6 The ERS reports that 12.7 percent (15.8 million) of U.S. households were food insecure at some time during 2013, including 5.0 percent (6.3 million) with very low food security.7 About 42.2 million people in the United States lived in food-insecure house- holds in 2015; 6.4 million of those households include children. About 5 percent of house- holds were in the lowest-level category, classified as “very low food security.”8

developed country Country that is advanced in multiple areas, such as income per capita, life expectancy, rate of literacy, industrial capa- bility, technological sophistication, and eco- nomic productivity.

food security Household-level economic and social condition characterized by reliable access to adequate amounts of healthy foods.

food insecurity Household-level economic and social condition characterized by uncertain access to adequate food.

We all know what hunger feels like. After a long day, a grumbling or gnawing in the stomach or feelings of fatigue or lightheadedness are signs that tell us we need to eat. However, how many of us know what it is like to be hungry day in and day out, never to feel truly full, or to lose weight even

though we don’t want to?

Conversely, how many of us, though we satisfy our hunger, are malnourished without realizing it?

As you learned in Chapter 2, malnutrition is a lack of proper nutrition. It may appear as undernutrition.

Typically, undernutrition is caused by not having enough to eat, not eating enough of the right things,

or being unable to use the food that one does eat, either because of repeated infections or poor nutrient

absorption.1 Children who are undernourished can’t grow properly and have an increased risk for a vari-

ety of diseases and death. Inadequate intake of vitamin A, for example, is a leading cause of blindness.

According to the World Health Organization (WHO), “an estimated 250,000 to 500,000 vitamin A–

deficient children become blind every year, half of them dying within 12 months of losing their sight.”2

Women who are undernourished during pregnancy risk giving birth to low-birthweight babies.3 The

health effects of undernutrition are discussed in detail later in this chapter.

Malnutrition may also appear as overnutrition, which can lead to overweight or obesity or a specific

micronutrient toxicity. Overnutrition and undernutrition may coexist, as when an individual consumes

a diet high in refined carbohydrates and low in micronutrients. Even people at a healthy weight may be

malnourished if they, like many Americans, are deficient in calcium, iron, or another micronutrient.

Who are the malnourished people in the United States and the rest of the world? What factors con-

tribute to this problem, and what can we do about it? Can one person’s actions really help people who

are hungry? In this chapter, we explore malnutrition, its causes and effects, and potential solutions in the

United States and around the world.

What Factors Contribute to Malnutrition in the United States? 781

Food Insecurity Is More Likely Among Certain Population Groups According to the ERS, Americans most likely to be very food insecure live in households with one or more of these life situations:9

• Households with children headed by a single parent • Single people living alone • Households with incomes below the poverty line • Black, non-Hispanic households or Hispanic households • Households located outside metropolitan areas (or rural)

For single parents heading a household, a lack of childcare may mean they can’t work enough hours, and expensive childcare arrangements can drain an already-tight budget. Single parents may feel stuck in low-wage jobs, unable to explore more lucra- tive career paths requiring training or higher education because of their obligations to their children. In 2015, about 30.3 percent of single women heading up a household with children experienced food insecurity.10

Single people living alone include seniors, and 9 percent of all seniors were food insecure in 2014.11 Seniors may be living on a fixed income and are less likely than other groups to enroll themselves in food-assistance programs.12 They may also be disabled or have chronic conditions that decrease their ability to shop for themselves.

People living in households with incomes below the poverty line are at greater risk of being food insecure. Poverty is the primary factor in food insecurity and is discussed separately in the next section.

Because they experience disproportionate levels of poverty, it is not surprising that African Americans and Hispanics also experience higher rates of food insecurity than the national average, with 21.5 percent and 19.1 percent experiencing food insecurity, respectively, in 2015.13 A number of factors may contribute to these statistics: African Americans experience unemployment at twice the rate of Caucasian Americans14 and Hispanics tend to have larger family sizes and lower household incomes, which can make feeding the whole family difficult.15

Those living in households outside metropolitan areas struggle with multiple chal- lenges to food security, including higher unemployment and lower wages, lower educa- tion levels, and lower access to affordable childcare and public transportation. Of rural households in the United States, 16.7 percent live below the poverty line and 15 percent are food insecure, with the South having the highest poverty rate.16 Between 2013 and

General Category

Level of Food Security

Description of Conditions in the Household

Food Security High food security No reported indications of food-access prob- lems or limitations.

Marginal food security One or two reported indications—typically of anxiety over food sufficiency or shortage of food in the house. Little or no indication of changes in diets or food intake.

Food Insecurity Low food security Reports of reduced quality, variety, or desirability of diet. Little or no indication of reduced food intake.

Very low food security Reports of multiple indications of disrupted eating patterns and reduced food intake.

Source: Adapted from USDA Economic Research Service. 2016. Definitions of Food Security. Available at https:// www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security.aspx. Accessed February 2017.

TABLE 21.1 Ranges of Food Security

In the United States, poor single parents and their children can experience food insecurity due to unemployment, low wages, or other circumstances that lead to financial hardship.

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food deserts Parts of the country, usually impoverished areas, where fresh fruits, veg- etables, and other healthful whole foods are scarce, largely due to a lack of grocery stores, farmers markets, and healthy-food providers.

2015, the six states with the highest food-insecurity rates were Mississippi, Louisiana, Arkansas tied with Maine, and Kentucky tied with Alabama.17 Figure 21.1 shows levels of food insecurity in all U.S. states.

College students, too, experience food insecurity. Recent studies found that 21 percent of students at the University of Hawaii, 39 percent of students at the City University of New York (CUNY), and more than half of the students attending certain colleges in Oregon, Maryland, and Alaska were food insecure.18,19,20,21,22 Some colleges are starting to offer campus food banks to support students who are food insecure. Does that include you? Take the Self-Assessment and find out.

Poverty Contributes to Food Insecurity Poverty is the principal cause of food insecurity in the United States. The U.S. Census Bureau estimated that for 2015, the poverty rate was about 13.5 percent of the United States population. The poverty rate in 2015 for children under age 18 was 19.7 percent.23 As of 2015, for a married couple or a single mother plus a child, poverty means a house- hold income below $15,391 per year. A family of four would be impoverished with an income below $24,036.24

In 2012, about 9.5 million adults were classified among the working poor.25 Though these people had jobs, they still had incomes below the poverty line. High housing and utility costs can consume most of the household budget and leave little money for food. Individuals in these households may be living “paycheck to paycheck.” An unexpected expense, such as an illness or a costly auto repair, can force the working poor to choose between paying the bills and consuming a healthy, adequate diet.

People living in poverty often reside in rural regions or inner-city neighborhoods lacking healthy food stores. These regions are technically known as food deserts.26 The U.S. Centers for Disease Control and Prevention (CDC) defines food deserts as areas

poverty Lacking the means to provide for material or comfort needs.

working poor Individuals or families who are steadily employed but still experience poverty due to low wages or high dependent expenses.

▲ Figure 21.1 Food Insecurity in the United States Though some areas of the United States have higher rates of food insecurity and/or hunger, these conditions can happen anywhere. In this map, data for 3 years, 2013–2015, were combined to provide more reliable statistics at the state level. Source: United States Department of Agriculture, Economic Research Service. Updated 2015. Food Security in the U.S.: Key Statistics & Graphics. Available at www.ers.usda.gov. Accessed April 2017.

Food insecurity below U.S. average

Food insecurity near U.S. average

Food insecurity above U.S. average

WA

OR

CA

NV UT

AZ

ID

CO

NM

TX

OK

LA

MS AL

FL

GA SC

NCTN

KY

AR

MO

IA

KS

IL IN OH

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MN

PA

NY

VT

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MA

RI

DC

CT NJ DE

MD

ME

VAWV

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SD

NDMT

WY

What Factors Contribute to Malnutrition in the United States? 783

without ready access to affordable fruits, vegetables, whole grains, lowfat milk, and other foods that make up the full range of a healthy diet.27 Food deserts exist all over the United States. You can look for your community in the USDA Food Desert Locator by going to www.ers.usda.gov and searching for food desert locator.

Illness and Disability Can Lead to Food Insecurity Adults who are chronically ill or disabled are less likely to earn a steady income and are therefore at increased risk of food insecurity. Even when they are employed, disease symptoms and health care appointments may cause them to miss work frequently. These absences can significantly reduce a paycheck, and thus available funds for food. Chronic illness and disability may also be accompanied by high out-of-pocket costs for medica- tions, which can deplete income that would otherwise be available for food.

Mental illness, including substance abuse disorders, can also contribute to food inse- curity. People who suffer from anxiety disorders, depression, schizophrenia, alcoholism, or drug abuse may lose interest in eating. These individuals may also find it difficult to get and keep steady employment, may have decreased access to cooking facilities, and may have difficulty shopping for and preparing nutritious food. In a vicious cycle, mental health problems among mothers and their children increase when mothers are food insecure.28

According to the National Coalition for the Homeless, some 20–25 percent of indi- viduals who are homeless are also mentally ill.29 People who are homeless can be difficult to reach, counsel, or help. They may be forced to rely on charity, church meals, or public assistance programs for most of their food.

Self-Assessment

Are You Food Secure? Take the quiz below to find out if you are at risk for food insecurity.

In the past 12 months:

1. Have you ever run out of money to buy food?

Yes □ No □

2. Have you ever eaten less than you felt you should because there was not enough money to buy food or enough food to eat?

Yes □ No □

3. Have you ever completely depleted your food supply because there was not enough money to buy replacement groceries?

Yes □ No □

4. Have you ever gone to bed hungry because there was not enough food to eat?

Yes □ No □

5. Have you ever skipped meals because there was not enough money to buy food?

Yes □ No □

6. Have you ever relied on a limited number of foods to feed yourself because you were running out of money to buy food?

Yes □ No □

Answers If you have no “Yes” replies, you are food secure. If there are one to three “Yes” replies, you are at risk for food insecurity. If there are four or more “Yes” replies, you are likely in the low or very low food-security category.

Sources: Adapted from The Community Childhood Hunger Identification Project Survey. 1995; Kleinman, R. E., Michael Murphy, et al. 1998. Hunger in Children in the United States: Potential Behavioral and Emotional Cor- relates, Pediatrics 101:3–10.

People in poor urban neighborhoods often find themselves in “food deserts,” with little access to fresh, healthy food found in supermarkets.

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What Factors Contribute to  Malnutrition around the World? LO 21.2 Describe the causes of malnutrition worldwide.

Of a global population now exceeding 7.5 billion people, a minority—about 1.2 billion— live in developed countries.30 The other 6 billion live in developing and least developed countries—collectively referred to as the developing world—where many lack full access to goods and services. The Food and Agriculture Organization (FAO) of the United Nations estimates that there were 795 million undernourished people in the world in 2014–2016.31 Figure 21.2 shows levels of undernourishment across the globe.

Malnutrition in the developing world is caused by a complex set of factors. Once again, poverty lies at the heart of the problem; however, discrimination, war and political unrest, agricultural challenges and food waste, climate change, natural disasters, resource depletion, and overpopulation all contribute to food insecurity for large numbers of peo- ple, particularly in Asia and Africa.

Discrimination Contributes to Malnutrition In many poor countries, discrimination at both the national and local levels contributes to malnutrition. For example, at the national level, control over land and other assets is often unequal, so that even increased crop yields do not decrease food insecurity.

developing country Country that is growing in multiple areas, such as income per capita, life expectancy, rate of literacy, industrial capability, technological sophistication, and economic productivity.

least developed country Country that shows little growth in multiple areas, such as income per capita, life expectancy, rate of literacy, industrial capability, technological sophistication, and economic productivity.

▲ Figure 21.2 Food Insecurity Worldwide, Levels of Undernourishment, 2014–2016 Food insecurity is a global problem. This map shows which areas of the globe are most profoundly affected. Source: FAO, IFAD, and WFP. 2015. The State of Food Insecurity in the World 2015. Available at www.fao.org. Accessed April 2017.

<5% very low 5%–>14.9% - moderately low 15%–>24.9% - moderately high 25% –>34.9% - high

Missing or insufficient data 35% and over - very high

LO 21.1: THE TAKE-HOME MESSAGE Food insecurity is the limited or uncertain access to foods of sufficient quality or quantity to live an active, healthy life. Food insecurity is more likely to affect single parents with children, single people, those living below the poverty line, black and Hispanic households, and people in rural areas. Factors that contribute to food insecurity and malnutrition in the United States include poverty, physical and mental illness, and disability.

What Factors Contribute to  Malnutrition around the World? 785

Very few people in certain developing countries own their own land, and a plentiful crop primarily benefits the landowner, not the farm laborer. Women, especially, suffer from discrimination.32

Cultural practices may also compromise access to food at the local or household level. In some cultures and within some families, the amount of food available to an individual is influenced by gender, control of income, education, birth order, and age. A study in Nigeria, for example, found that men controlled the household income and had prefer- ence in household food sharing.33 Gender inequity is a serious problem worldwide. In many cultures women and girls are viewed as less valuable than men and boys, and they therefore receive less food and education. Of the 17 percent of the world population that is illiterate, two-thirds are women.34 Young women are also disproportionately affected by lack of employment opportunities.35

Political Sanctions and Armed Conflicts Disrupt the Food Supply Political sanctions can create or intensify food shortages by decreas- ing a population’s access to agricultural supplies, fuel, or food imports. They can also result in higher local prices for fuel, food, and other essentials. Sanctions that block exports to other countries can also contribute indirectly to a failing economy by decreasing household income when workers in businesses that rely on this trade lose their jobs. All of these factors can lead to widespread food short- ages that may cause a collapse in food production and distribution and, ultimately, widespread malnutrition.36

According to the World Food Programme, armed conflicts are another major cause of world malnutrition.37 War and civil and political unrest lead to malnutrition by disrupting agriculture, food distribution, and normal community activities. During the past two decades, the world has experienced terrorism, tribal and religious warfare, and civil war in countries such as Somalia, the Democratic Republic of Congo, and Syria. During wars and regional con- flicts, government money is often diverted from nutrition and food distribution programs and redirected toward weapons and military support. Moreover, political turbulence can compromise humanitarian food distribution efforts, making it difficult for food aid to reach the people in need. In some cases, assistance programs and aid workers have to abandon war-torn areas and curtail their relief efforts.

Agricultural Challenges and Food Waste Limit the Food Supply Because of advances in agricultural technologies, including the introduction and wide- spread adoption of genetically modified high-yield crops, world agriculture produces 17 percent more kilocalories per person today than it did 30 years ago, which is enough to provide everyone in the world with at least 2,700 kilocalories per day.38 Unfortunately, these advances are leading to the loss of genetic diversity of plants, damaging use of pesticides, evolution of pesticide-resistant pests, pollution by run-off of fertilizers, and depletion of water reservoirs. While these practices may increase crop yield in the short term, they are unsustainable in the long term.39

Moreover, agricultural challenges still persist in many regions, contributing to global food insecurity. A lack of access to information about modern farming practices, seeds, and equipment can keep farmers from reaching the land’s full potential. Establishing effi- cient irrigation systems is another major challenge. Underground drip systems allow farm- ers to water crops accurately, without wasting water, and yet such systems are expensive

Many hunger relief programs work to provide food aid to nations in conflict. However, successfully delivering the food to those who need it is often challenging.

Thanks to agricultural advances, the world’s farmers can grow plenty of food. However, distribution problems and other factors keep some people from getting enough to stave off hunger.

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to buy and require some knowledge to install and maintain. Furrow irrigation systems, which are inexpensive and simple, can get water where it needs to go, but water is lost in transit, and these systems cause soil erosion.40

Finally, an astonishing one-third of all food produced is never consumed.41 Accord- ing to the FAO, tons of food is wasted all along the food chain from farm to table, with larger losses occurring during agricultural production in developing countries, and at the consumer level in wealthier regions—like the overripe bananas no one purchases at the grocery store.42 Tackling the food waste problem involves reducing production to meet actual demand, directing surplus to regions in need, and responsibly recycling what can’t be reused. For ideas on how you can reduce food waste, see the Table Tips.

Climate Change, Natural Disasters, and Depleted Resources Limit Food Production Climate change is affecting Earth’s ability to produce food. We see evidence of this in droughts, floods, record-breaking heat waves, and emerging crop diseases and infestations around the world, all of which ruin crops. In the United States, technological advances can help farmers cope with the effects of climate change, and relief programs can help affected communities. Nevertheless, devastating weather events can still wipe out crops.43 In contrast, in the developing world, the effects of climate change and natural disasters can completely devastate communities. In just one example, entire villages in southern Madagascar are in the midst of famine as a result of a persistent drought attributed to climate change. Lack of communication and transportation systems, inadequate funding for relief programs, an inability to relocate populations from disaster-prone areas, and the incapacity to make homes and farms less vulnerable to destructive weather forces can all contribute to the problem.

Drought is the leading cause of severe food shortages not only in Madagascar but throughout the developing world. When drought conditions exist, crops cannot be adequately irrigated. In addition, access to safe and clean drinking water becomes limited, increasing a population’s risk for infectious disease and dehydration. Undernutrition results, particularly in people who depend on agriculture for both food and income. Lack of water can even force livestock owners to slaughter part of their herd or sell animals at “distress sales.” 44

Floods and excessive rain can also destroy food crops and are major causes of food shortage. For example, in India, more than 70 percent of the annual rainfall occurs during the 3 months of monsoon season. Farmers must contend with water scarcity for 9 months of the year only to be faced with crop failure later if monsoon rains are overly heavy.

Depletion of natural resources also threatens the world’s food supply. Water is one example; this natural resource is not infinite. About 3 percent of the water on Earth is fresh water, and most of that is locked up in ice or inaccessible underground.45 Industrial waste, pesticides, and untreated human wastewater pollute the fresh water supply and make it unusable for drinking water.46 Agriculture uses about 70 percent of the avail- able fresh water, and yet wastes about 60 percent of this water through leaky irrigation systems, inefficient watering systems, and poor choice of crops for the land.47 Without better management, a lack of water will reduce the food supply.

Overpopulation Leads to Food Scarcity The world population is projected to reach 8.5 billion people by 2030, and 9.7 billion by 2050.48 Much of this growth is taking place in the least developed regions, where the population is expected to increase from about 900 million people currently to 1.8 billion in 2050, as shown in Figure 21.3.49 Whenever rapid population growth occurs in areas that are strained for food production, the resulting overpopulation can take a toll on the local people’s nutritional status.

famine Severe shortage of food caused by weather-related crop destruction, poor agricultural practices, pestilence, war, or other factors.

overpopulation Condition in which a region has more people than its natural resources can support.

TABLE TIPS

Reducing Food Waste

Shopping tips:

Plan out meals for a week at a time.

Check your fridge and cabinets before you shop.

Buy only foods you really need.

When you shop, stick to the list!

Cooking and storage tips:

Understand and use expiration dates properly.

Use up older foods in the fridge first.

Have “leftover night” once a week.

Compost!

Serve yourself only what you can eat.

Cook meals in large batches; freeze portions for later.

Shortsighted farming techniques can deplete natural resources and take a heavy toll on crops and farmland.

What Factors Contribute to  Malnutrition around the World? 787

People in the developing world tend to have more children than people in developed regions for a variety of reasons. The infant and child mortality rate is high, so parents have more children to ensure that some of their offspring survive into adulthood. Large families are also needed to work on farms to help generate income and to support older family members later in life. Additionally, women in developing regions have reduced access to reliable methods of contraception, higher education, and career opportunities, all of which work to limit family size in developed nations. The World Bank promotes gender equality and development to break this cycle and ensure that girls and women receive a basic education.50

The Nutrition Transition Can Contribute to Malnutrition Ironically, malnutrition is not confined to those who are food insecure or even hungry. In countries that are becoming more prosperous, while people are getting more food to eat, they are not necessarily eating high-quality food. As nations get richer, people who formerly ate meals full of vegetables and grains may shift over to diets higher in saturated fats and sugars. And as workers move from rural locations to cities, and from agricultural jobs to sedentary jobs, they get less exercise. These factors contribute to a so-called nutrition transition that leads to overweight, obesity, and potentially malnutrition.51

One of the hallmarks of populations in nutrition transition is the coexistence of undernutrition and overnutrition in the same community, as some community members thrive while others remain in desperate poverty. This coexistence of under- and over- nutrition can also be seen within a single family or even in individuals. The boys in a family may be overweight, for example, while the girls are underweight, or an individual may be obese but deficient in certain micronutrients.52 This phenomenon is called the double burden of malnutrition.

nutrition transition Shift in dietary consump- tion and energy expenditure that may occur as people in developing countries shift from their traditional diet to diets higher in sugar, fat, and animal-based foods.

▲ Figure 21.3 World Population Growth The majority of people in the world live in developing countries, and this number is expected to grow. Source: United Nations Population Division. 2015. World Population Prospects: The 2015 Revision, medium variant. Available at http://esa.un.org. Accessed April 2017.

Less developed regiom s

9 10

8 7 6 5 4 3 2 1 0 1950 60 80 2000 20 40

Po pu

la tio

n (b

illi on

s)

70 90 10 30 50 60 70 80 90 2100

Least developed regions

More developed regions

LO 21.2: THE TAKE-HOME MESSAGE Factors that give rise to malnutrition around the world include poverty, discrimination, political sanctions and armed conflicts, poor agricultural practices and food waste, climate change, natural disasters, resource depletion, overpopulation, and the nutrition transition.

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Which Populations Are at Greatest Risk for Malnutrition Worldwide? LO 21.3 Identify populations that are at greatest risk for malnutrition.

Because of their increased nutritional needs, infants, children, and pregnant and lactating women are at higher risk for malnutrition worldwide than are other groups. Older adults, people who are ill, and people living in poverty are also at increased risk.

Pregnant and Lactating Women Are at Increased Risk for Malnutrition As discussed in Chapter 17, nutrient requirements increase during pregnancy and lactation. Pregnant women need extra kilocalories and nutrients—in particular, protein, vitamins, and minerals—to support a healthy pregnancy. In general, during the first 6 months of a pregnancy, the majority of the additional kilocalories are used to nourish the mother as her body undergoes the changes necessary to support a pregnancy. During the last 3 months of a pregnancy, the majority of extra kilocalories are needed by the growing fetus to increase fetal reserves of protein, fat, and various micronutrients.53 Improperly nour- ished pregnant women often give birth to malnourished infants.

Because human breast milk is the ideal nourishment for infants, women throughout the world are encouraged to breastfeed their babies. The global recommendation is for women to nurse their babies for the first 6 months and to continue nursing with supple- mental foods into the child’s second year of life.54 Ideally, a woman of average weight who is breastfeeding would eat about 500 extra kilocalories per day to stay properly nourished. If this doesn’t happen, the mother, and possibly the baby, will lose weight.55

One qualification to the breastfeeding recommendation applies to women who are HIV positive. Mothers with HIV risk passing the virus to their infants through breast milk, and therefore should be encouraged to use formula that is either canned or made from powder mixed with boiled, cool water, or to employ a noninfected wet nurse to feed their babies. However, HIV-positive women who can’t afford these alternatives are advised to breastfeed their children. In these cases, the benefits of providing the nutrients in the breast milk, coupled with the risks of infection from making formula from contami- nated water, outweigh the risks of passing the HIV infection on to the baby.

Infants and Children Are Highly Susceptible to Malnutrition Infants are particularly susceptible to malnutrition because they are growing rapidly and have high nutrient requirements (per unit of body weight). Infants whose mothers are mal- nourished themselves are at particularly high risk for malnutrition because their mothers’ supply of breast milk will be reduced.

After 6 months of age infants require solid food in addition to breast milk, which puts them at increased risk for malnutrition if food supplies are limited. As an infant transitions from an all–breast milk diet to a diet of breast milk plus solid foods, she or he is also at risk for improper weaning, which can lead to diminished growth during the first year of life and the potential for severe malnutrition during the second year of life.56 Babies may be given foods that are inappropriate—too high in dietary fiber, for example, or too low in protein. During the sixth to twelfth months of life, children may be more likely to be exposed to contaminated food and water, which may cause diarrhea and dehydration. When infants begin to crawl and walk, their risk of exposure to and thus infection by bacteria and parasites increases. Some parasitic infestations cause nutritional deficien- cies directly. For example, hookworms suck blood from the lining of the gut, causing iron-deficiency anemia.

Because of the increased nutrient needs associated with pregnancy, lactation, and early childhood growth, mothers and their young children are at particular risk for malnutrition.

Which Populations Are at Greatest Risk for Malnutrition Worldwide? 789

The risk of malnutrition continues from infancy into early childhood and may result from food shortages within the family or chronic disease. If there is a severe lack of protein in the diet, for example, children may develop kwashiorkor (see Chapter 6). Malnourishment also builds on itself: Children who are ill or malnourished have poor appetites—their normal hunger sensations are diminished. In some children maldigestion and malabsorption exacerbate the problem by increasing the loss of nutrients.

The loss of one or both parents from disease may also lead to decreased family income and a greater risk of malnourishment. For example, about 17 million children in the world have lost one or both parents to HIV/AIDS in the last 30 years, increasing their risk of malnutrition.57 An estimated 36.7 million people in the world had HIV/AIDS in 2015, including 1.8 million children under age 15.58 Most of these children were born to mothers with HIV or obtained the virus during infancy (via childbirth or breastfeeding).

The Ill and the Elderly Are Also at High Risk for Malnutrition People who are chronically ill may have malabsorption problems that reduce their nutri- tional status. Liver and kidney disease can impair the body’s ability to process and use some nutrients. Some cancer patients and many people with AIDS experience loss of appetite, which reduces their kilocalorie intake and further complicates their treatment.

Although older adults need fewer kilocalories due to a decrease in their metabolic rate and lower levels of physical activity, they have higher requirements for vitamin D, vitamin B6, and calcium, and are thought to need more protein per kilogram of body weight, as compared to younger adults. Older people may be at risk for nutrient deficiencies because of a decreased sense of taste and smell, immobility, malabsorption, or chronic illnesses. Loneliness, isolation, poverty, missing teeth, confusion, or disinterest in cooking and eat- ing also contribute to malnutrition. In addition, most elderly people, whether in the United States or in other countries, live on a fixed income or have no income at all and must depend on family members to provide for them. In such cases, food is often stretched, and meals are smaller or are skipped altogether. All of these factors contribute to an increased rate of food insecurity and malnutrition in the older adult population.

People Living in Poverty Have Unique Risk Factors for Overnutrition Unfortunately, overweight among those who are food insecure is common. High-fat, high- kilocalorie diets are more affordable than diets based on lean meats, fish, vegetables, and fruits. There is a clear link in women between food insecurity and overweight and obesity. Research suggests that mothers often restrict their food intake during periods of food insufficiency to protect their children from malnutrition, and then overcompensate when food is available. These chronic ups and downs of food intake can contribute to obesity.59

For those living on a limited budget, filling their cupboards with food, even if that food is low in nutrients, takes precedence over choosing foods with nutritional value. If they live in a food desert, people who are poor may not even have access to nutritious foods.

Living in poverty increases stress,60 but sugar consumption has been shown to reduce secretion of the stress hormone cortisol.61 This may make foods high in added sugars particularly appealing as a way to manage the chronic stresses of poverty.

Finally, cheaper foods tend to be low in protein and high in kilocalories. To get the same level of satiety, you would have to eat more kilocalories from chips and candy than you would from a high-protein snack like a hard-boiled egg. As you have learned from previous chapters, a diet high in empty kilocalories and low in nutrient-dense kilocalories can increase the risk of overnutrition.

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How Can We Reduce Hunger? LO 21.4 Explain several ways to reduce hunger.

In the United States, hunger relief efforts exist at many levels. At the local level, individu- als, families, churches, and community relief agencies seek out and assist people who have insufficient resources. Examples of assistance include hot meals and free food provided by local shelters and food banks, as well as education and job training provided by local and state governments, nonprofit organizations, and faith-based organizations. See the Spotlight on America’s Second Harvest for more information about food banks and how you can help.

The U.S. government also engages in hunger relief efforts, providing food aid and cre- ating economic opportunities for people who want to improve their lives. The USDA, for example, spent over $104 billion in 2015 on numerous food assistance programs to feed Americans in need.64 Table 21.2 identifies some of the main USDA food assistance programs.

LO 21.3: THE TAKE-HOME MESSAGE Pregnant and lactating women, infants and children, and the ill and elderly are particularly vulnerable to malnutrition. People who are poor have unique risk factors for overnutrition, which is a form of malnutrition.

Program Eligibility Description Prevalence

Supplemental Nutrition Assistance Program (SNAP; formerly the Food Stamp Program)

Low income (for a family of four in 2016, the net monthly income could not exceed $2,025)

Eligible individuals are issued a debit card to purchase food at their local authorized supermarket. (Items such as alcohol, tobacco, nonfood items, vitamins and medicines, and hot foods are not covered.)

In 2016, more than 44.2  million people per month in the United States

Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

At-risk low-income pregnant and lactating women, infants, and chil- dren less than 5 years old

The program provides nutritious, culturally appropriate foods to supplement the diet. The program also emphasizes nutrition education and offers referrals to health care providers

About 8 million women, infants, and children per month in 2015

National School Lunch Program; School Breakfast Program

Children with families with incomes at or below 130% of the poverty level are eligible for free meals and those with incomes between 130% and 185% of the poverty level are eligible for reduced-price meals

Eligible children receive free or reduced-price lunches and/or break- fasts at school each day.

More than 30 million Ameri- can children joined the lunch program in 2016, and almost 14.5 million children par- ticipated in the breakfast program

Summer Food Service Program

Available to communities based on income data

Federal program that combines a meal or feeding program with a summer activity program for children

During 2016, more than 2.8 million children daily at 42,654 sites

Child and Adult Care Food Program

Available to communities based on income data

Program provides nutritious meals to low-income children and older adults who receive daycare or adult care outside the home. There are income guidelines for program participation

More than 4.4 million children and adults receive meals and snacks each day as part of this program

Congregate Meals for the Elderly and Meals on Wheels

Age 60 or over The programs provide meals at a community site or delivered to the home

More than 1 million meals per day served at sites across the country

Sources: Data from USDA, Food and Nutrition Service. 2017. Supplemental Nutrition Assistance Program (SNAP), WIC Program, National School Lunch Program (NSLP), Summer Food Service Program, Child/Adult Care Food Program, www.fns.usda.gov. Meals on Wheels Association of America. 2017. www.mowaa.org.

TABLE 21.2 Food Assistance Programs in the United States

How Can We Reduce Hunger? 791

When it comes to fighting hunger in America, everyone needs to pitch in. You can help your needy neighbors in three ways: give funds, give food, and give time. Funds can be donated online at www.secondharvest.org. You can donate food by hosting a food drive. Finally, you can volunteer your time by helping out in your local community, perhaps by tutor- ing children on healthy eating practices, repackaging donated food, stocking shelves at a local food pantry, or trans- porting food to the hungry.

To find out where you can help, visit the America’s Second Harvest website (www.secondharvest.org) and click on the volunteer link.

centers and gather and transport the donated foods to local food pantries or emergency kitchens. Volunteers and workers also staff food rescue organiza- tions that “rescue” prepared foods, such as ready-to-eat surplus items from ban- quets, company and college cafeterias, and restaurants, that would otherwise go to waste.63 Sometimes food rescue cen- ters are located in the same building as food banks.

food pantry Community food assistance location where food is provided to needy indi- viduals and families.

emergency kitchen Kitchen or a commercial food service that prepares for natural disasters, emergencies, or terrorist attacks.

Food insecurity may be closer than you think. In fact, you may have friends, relatives, or neighbors who’ve experienced hunger sometime in their lives, or perhaps you’ve been hun- gry yourself.

America’s Second Harvest, the largest hunger relief organization in the United States, was started to help individuals who are routinely without food. The mis- sion of this organization is to eradicate hunger and ensure that no American goes to bed hungry. They redistribute excess and donated food and grocery items, work to increase public awareness of hunger, and advocate for those who are hungry. America’s Second Harvest distributed more than 52 million pounds of food from July 2015 through June 2016, through partnerships with over 320 nonprofit agencies.62

America’s Second Harvest stores surplus food from national food compa- nies and other large donors in a central- ized location. Volunteers travel to these

Hunger Among Us (and How You Can Help!)SPOTLIGHT

Everyone—from children to adults—can help eradicate hunger.

In addition to the human (person-to-person) help provided by people and organiza- tions, technology also plays a role in alleviating malnutrition by improving agricultural techniques, land management, water use, and sanitation and by fortifying common foods with iodine and other micronutrients of concern. The following discussion looks at a number of these solutions.

Improve Agriculture The long-term solution to malnutrition in any given region requires balancing the number of people in that region with the amount of food that can be locally produced. Even where poverty is widespread, the region’s capacity to feed its population can be increased by devel- oping manageable systems for producing food.65 Crop sales gener- ate income that not only benefits the landowners and workers, but travels throughout the community to significantly decrease poverty and help reduce malnutrition.

Biotechnology, specifically the production of genetically modi- fied foods, can create crops with increased yields and pest resistance. Some staple crops, such as corn and rice, can be bioengineered to contain an increased level of nutrients. Biotechnology can also be used to improve the taste or shelf-life of fruits and vegetables.

On the other end of the spectrum, many farmers are turning to organic farming. In organic farming, as defined by the USDA,

Better land management, appropriate crop selection, and biotechnology can all help eliminate malnutrition.

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farmers do not use genetically modified organisms or toxic or persistent pesticides or fer- tilizers. They do support animal health and welfare, provide outdoor access for animals, use only approved materials, receive annual onsite inspections, and separate organic from nonorganic food. They thus preserve natural resources and biodiversity and reduce pol- lution.66 As the soil on organic farms becomes balanced, the crops growing there tend to become healthier, and more disease resistant. While the yield from an organic farm may be lower than that of an industrial farm, organically grown plants tend to be more drought resistant.

In areas of Africa, farmers have had success leveraging the natural qualities of local plants as protection, where pests, climate change, and soil degradation have caused chronic food insecurity. For example, the local cereal crop, grown for its nutritional value, is planted with companion plants chosen specifically for their value in discouraging pests and nourishing the soil by capturing nitrogen. The whole field is then surrounded by a border of a third plant that attracts pests away from the main crop. Plants are chosen for their drought-resistant qualities as well. With better soil and fewer pests, the cereal crop can thrive and grain yields are higher.67

If farmers raised more crops for human consumption rather than for food-animal consumption, they could, generally speaking, feed more people. Right now, only a little over half of the world’s crop kilocalories—kilocalories available from crops grown— actually feeds humans. About 36 percent goes to feed animals that are raised for human consumption. If we grew a greater percentage of crops for human consumption, rather than for raising meat, we could increase available kilocalories by as much as 70 percent.68

Increasing farmers’ land ownership can also increase food security. Farmers who own their land are motivated to make better decisions regarding irrigation, crop rotation, land fallowing (leaving land plowed but unplanted), and appropriate soil management.69 Unfortunately, land ownership is not evenly distributed across most populations. This situation is unlikely to change without land reform, in which governments create rules to reallocate land to landless people. In some countries, grassroots programs are providing access to land for women and their families for the purpose of growing food.

Improve Water and Sanitation At least 1.8 billion people worldwide lack access to safe drinking water.70 Providing safe water is critical in reducing malnutrition. The CDC stated in 2015 that 88 percent of all diarrheal illnesses in the world are attributable to unsafe water or inadequate sanitation.71 Because diarrhea reduces nutrient absorption, a person who has diarrhea is at increased risk for malnutrition.72

Some innovative solutions are being proposed to alleviate the world’s safe water problems. In some communities in Asia, Africa, and Latin America, for example, solar energy is used to thermally purify the water supply.73 Water is poured into plastic PET jugs that are placed on black-covered roofs and allowed to heat for several hours. Once the temperature of the water exceeds 50°C (122°F), it becomes safe to drink. The heat and UV radiation effectively destroy common waterborne bacteria, viruses, and pathogens such as those that cause cholera, typhoid, dysentery, polio, and diarrhea.

About 2.4 billion people (36 percent of the developing world’s population) lack basic sanitation facilities like flush toilets or cov- ered latrines. They still use open-pit toilets or simply defecate on the ground.74 Lack of proper toilets and sewage systems can lead to the contamination of rivers and groundwater. Poor sanitation is linked to the spread of diseases such as cholera, diarrhea, hepatitis A, and other communicable diseases.

Access to clean drinking water is just as important as adequate nutrition for human health.

How Can We Reduce Hunger? 793

One initiative to improve sanitation in developing countries comes from the Gates Foundation, which has challenged engineers to create a toilet that would be cost effec- tive, that would operate in conditions that mimic those in developing countries— without electricity, sewer lines, or water lines—and that would recapture energy, clean water, and nutrients from human waste. Developers are testing such toilets in India and China.75

Fortify Foods to Raise Nutrient Levels Globally the most common micronutrient deficiencies include iodine, iron, and vitamin A. The fortification of staple foods with nutrients can help to alleviate these deficiencies. For food fortification to work, the staple foods must be shelf-stable, affordable, and con- sistently available in the food supply. Rice, cereals, flours, salt, and even sugar are examples of foods that can be successfully fortified.

Because food fortification is inexpensive, as well as enormously beneficial, fortifica- tion programs are being developed and implemented worldwide. Countries all across the globe fortify foods such as flour, salt, oil, sugar, and soy sauce with iron, iodine, and vitamin A.76

Promote Education Education plays a critical role in improving food security, both directly and indirectly. Educating farmers on best agricultural practices—including crop rotation, irrigation, and fertilization—for sustainable farming can directly improve agricultural productivity, which in turns improves the chances of achieving food security.77

Education indirectly affects food security by reducing population growth. Educating girls and women is of particular importance: as noted earlier, population growth slows and children are healthier when women are educated.78 Education must also focus on developing literacy, technical knowledge, agricultural skills, horticulture, human health and reproduction, and the preservation of natural resources.79

Assistance Programs Are Working to End Hunger Around the World Across the globe many large and small international organizations are working to end hunger. The World Food Programme, which has the goal of getting to “Zero Hunger,” provides hundreds of thousands of tons of food per year to people in need, and this is only one of its programs—it also provides cash and vouchers to people who have access to food but not enough money to buy it, and it has programs to put people to work to improve their community and get paid in food.80 Another large organization, UNICEF, channels money for humanitarian aid from people in developed countries to help feed children in need in developing countries. UNICEF was founded after World War II to help children in war-torn countries, and it continues to help children worldwide today.81

The group Heifer International has the goal of ending poverty by providing families with animals such as sheep, goats, cows, or ducks.82 The idea is that families can become self-sufficient and also sell surplus milk, eggs, and wool. The group also provides tools and training. Making families self-sufficient can help to lift them out of poverty.

The Peace Corps is another organization that helps reduce malnutrition by giving people the training and support they need to change their own situation. In one initiative, volunteers are helping to make sure girls get a chance to go to school. In another, they are helping local people establish sustainable methods to feed themselves, not just by growing more food, but by learning about health and nutrition.83

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LO 21.4: THE TAKE-HOME MESSAGE Reducing malnutrition benefits everyone. Local charities and community groups, corporations, and governments can pro- vide aid and organize programs to alleviate hunger. Improvements in agriculture, including both biotechnology and organic farming, help increase the food supply. Improving access to clean water and sanitation is essential as well. Food fortification programs increase the levels of iodine, iron, and other micronutrients of concern in the food supply. Education of the world’s population is also important. Several pro- grams around the world help with global poverty and hunger.

HEALTHCONNECTION

Children Suffer Impaired Growth and Development The bodies of children who are undernour- ished compensate for a lack of food by decreasing physical and mental growth. An undernourished child is therefore likely to experience both physical and mental prob- lems, including insufficient weight gain and reduced height, inadequate muscle develop- ment, lowered resistance to infection, and impaired brain development (Figure 21.5).85

Malnourished children experience growth stunting (lower than expected height for age). Globally, an estimated

156 million children experienced stunting in 2015, and about 145 million of these chil- dren lived in Africa and Asia.86 Deficiencies of energy, protein, iron, and zinc, as well as prolonged infection, have been implicated as causes. In 2015, about 50 million children under 5 years old in the developing world suffered from wasting (decreased weight for age).87

If malnutrition occurs at early, crucial times of brain development, cognitive development is impaired.88 Reduced cog- nitive development can in turn result in permanent lower intelligence and impaired learning. As a result, malnourished children may be unable to complete an elementary education and therefore have a reduced income-earning ability later in life. For example, iodine deficiency in a pregnant woman’s diet can result in congenital hypo- thyroidism, also known as cretinism, in her child. In severe cases, the child may have brain damage, deaf-mutism, squinting, and difficulty walking.89 The condition may be prevented by providing enough iodine in the mother’s diet—typically via the use of iodized salt. According to the WHO, iodine deficiency is the most preventable cause of brain damage, and salt fortification programs are “spectacularly simple [and] universally effective.”90

During their school years, children are more likely to show behavioral, emotional, and academic problems if they come from families that experience food insecurity. In particular, long-term undernutrition is associated with increased anxiety, irritabil- ity, attention problems, and school absence and tardiness rates.91 Even if malnourished

growth stunting Impaired growth and devel- opment caused by undernutrition primarily in childhood. Once growth stunting occurs, it is usually permanent.

wasting Diminishment of muscle and fat tis- sue caused by extremely low energy intake.

What Are the Effects of Chronic Undernutrition? LO 21.5 Describe the health conse- quences of undernutrition.

The detrimental health effects of acute undernutrition can be reversible. In contrast, persistent undernutrition can prompt a downward health spiral that is hard to reverse (Figure 21.4).84

In times of reduced kilocalorie intake, such as when dieting to lose weight, fast- ing, ill, or experiencing famine, the body attempts to conserve energy and preserve body tissues by lowering basal metabolism. As the kilocalorie deficit continues, the body begins to break down its own tissues for energy. This results in the reduction of stored fat and ultimately the deterioration of internal organs and muscle mass. In prolonged starvation, adults can lose up to 50 percent of their body weight. The great- est amount of deterioration occurs in the GI tract and the liver; the loss is moderate in the heart and kidneys; and the least dam- age occurs in the brain and other parts of the nervous system.

Let’s look at some individual effects of malnutrition.

▲ Figure 21.4 Downward Spiral of  Hunger and Malnutrition Lack of food can lead to numerous other symp- toms that compound the problem of hunger.

Lack of food

Compromised health and disease

Malabsorption in GI tractLoss of

muscle mass

Weight loss

Decreased growth

Anemia

Fatigue, apathy, no ambition

HEALTHCONNECTION (CONTINUED)

What Are the Effects of Chronic Undernutrition? 795

children are healthy enough to regularly attend school, they tend to be fatigued, inattentive, and unresponsive to their learn- ing environment. Peers, teachers, and adult caregivers may neglect a child who does not respond to or interact with others.

Weakened Immunity Results in Disease A malnourished individual has a weak- ened immune system, which increases his or her vulnerability to various infec- tions. Fever, parasitic disease, pneumonia, measles, typhoid, cholera, diarrhea, and malaria are examples of conditions that can occur because of weakened immune systems and chronic malnutrition. Diarrhea alone kills an estimated 2.2 million people globally each year.92

The WHO estimates that about 45 per- cent of all childhood deaths in developing countries are associated with malnutrition.93 The diseases that most commonly cause death in postneonatal children (i.e., those

▲ Figure 21.5 Symptoms of Starvation As hunger persists, physical symptoms set in and lead to further complications.

Overall: Withdrawn, lethargic, apathetic toward living

Eyes: Poor night vision, inadequate tear production

Teeth and gums: Teeth prone to chip, decay, or loosen

Heart: Abnormal pulse, circulatory difficulties

Hair: Unhealthy and discolored

Skin: Rashes, sores, or peeling skin

Mouth and lips: Dry and sore

Abdomen: Swelling

Muscles: Weakness, atrophy, low muscle mass for gender and age

Liver: Enlarged and tender; poor functional ability due to low protein in diet. Also depleted glycogen reserves.

GI tract: Diarrhea, malabsorption, or constipation

who survive birth and the first 28 days of life) are pneumonia, diarrhea, and malaria (Table 21.3), and malnutrition—by impair- ing the immune system—makes children more vulnerable to these diseases.94

A deficiency of certain micronutri- ents contributes to weakened immunity. Vitamins A, C, and E, for example, are critical to a healthy immune response, as are copper, iron, selenium, and zinc. In addition to promoting a healthy immune response, supplemental use of zinc can reduce the severity and duration of diarrhea.95

Infant and Child Mortality Rates Increase Malnutrition is part of a vicious cycle that passes hunger and illness from one genera- tion to the next. Unfortunately, many young women experience undernutrition during their own infancy and childhood. About half of all pregnant women and about 40 percent of preschool children in the developing world are thought to be anemic.96 In many developing countries the rate of low birth weight is as high as 30 percent.97 Girls who were low birth weight babies or were under- nourished and ill during the first 5 years of life may be physically stunted and less able to support a healthy pregnancy when they become adults. As we’ve seen, infants born to malnourished women are more likely to be malnourished themselves, to experience chronic illness, and to have an increased risk of premature death.98

Disease/Condition Cause Effect

Diarrhea Pathogenic infections Severe dehydration

Acute respiratory illness

Virus or bacteria Pneumonia, bronchitis, colds, fast breathing, coughing, and fever

Malaria Parasite (transmitted by a mosquito)

Flu, weakness, sweating, shivering, shaking, nausea, liver failure, infected red blood cells, and kidney failure or bleeding in the kidneys

Source: World Health Organization. Media Centre. 2017. Children: Reducing Mortality. Available at www.who.int. Accessed May 2017.

TABLE 21.3 Common Causes of Death in Malnourished Children

LO 21.5: THE TAKE-HOME MESSAGE The effects of chronic undernutri- tion can be severe and irreversible, depending on the stage of life. If undernutrition occurs during adult- hood, the body first attempts to conserve energy by slowing basal metabolism, and then breaks down tissues for energy. The physical effects of undernutrition in infants and chil- dren include stunted growth, wasting, impaired cognitive development and academic performance, reduced immunity and higher likelihood of infectious disease, and increased infant and child mortality.

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Visual Chapter Summary LO 21.1 Several Factors

Contribute to Malnutrition in the United States Hunger and malnutrition are health conditions that can result from food insecurity. In the United States, food insecurity and malnutrition can occur anywhere, includ- ing in rural areas, inner cities, and suburbs. People may get too few nutrients and suffer from undernutrition, or they may eat too many or the wrong kind of nutrients, as in overnutrition. Causes include poverty, disease or dis- ability, lack of education, and inadequate wages. People living in food deserts are at risk of malnutrition. Disease, disability, mental illness, and/or drug and alcohol abuse can lead to food insecurity, and sometimes contribute to homelessness, which in turn often results in hunger.

LO 21.2 Multiple Factors Contribute to Malnutrition Worldwide Despite abundant food production, many people around the world suffer from chronic hunger, food insecurity, and malnutrition. The majority of the world’s people live in developing countries where access to resources may be limited. Discrimination, political sanc- tions, armed conflicts, agricultural challenges, food waste, climate change, natural disasters, resource depletion, and overpopulation contribute to malnutrition in many countries. As a country becomes more prosperous, it may undergo a nutrition transition in which the population has access to more, but not necessarily better, food.

LO 21.3 Pregnant and Lactating Women, Children, the Ill, and Older Adults Are at Greatest Risk for Malnutrition Pregnant and lactating women have higher kilocalorie and nutrient needs. If they are improperly nourished, their infants may be, too. Infants and chil- dren in general have high nutrient needs because they are growing rapidly. They are dependent on their caregivers for food, making them more sus- ceptible to food insecurity. Chronically ill people may have malabsorption or metabolic problems or a reduced appetite. Older adults may be at risk for malnutrition because of higher needs for certain micronutrients, decreased senses of smell and taste, chronic illness, compromised immunity, and lack of mobility. People who are poor have unique risk factors for overnutrition, which is a form of malnutrition.

Check Your Understanding 797

LO 21.4 Agricultural and Organizational Efforts Can Reduce Malnutrition Agricultural practices such as using genetically modified high- yield crops and organic farming can help to reduce malnutrition, and safe water and sanitation practices are crucial to reducing ill- ness. Because deficiencies of iron, iodine, and vitamin A are most common, these are the nutrients most often used to fortify foods.

Community organizations can help ease malnutrition by providing free food and meals and assistance programs to help people overcome poverty and food insecurity. Corporations and governments can invest in biotechnologies and education pro- grams that provide more nutrient-dense foods and increase eco- nomic opportunity. The USDA funds multiple food assistance programs throughout the United States.

LO 21.5 Chronic Undernutrition Results in Disease and Death Effects of undernutrition include stunted growth, wasting, and impaired cognitive development and academic perfor- mance. Reduced immune function increases vulnerability to infections. Infants and children who are malnourished are at increased risk for early death.

Lack of food

Compromised health and disease

Malabsorption in GI tractLoss of

muscle mass

Weight loss

Decreased growth

Anemia

Fatigue, apathy, no ambition

Terms to Know ■ developed country ■ food security ■ food insecurity ■ poverty

■ working poor ■ food deserts ■ developing country ■ least developed country ■ famine ■ overpopulation

■ nutrition transition ■ food pantry ■ emergency kitchen ■ growth stunting ■ wasting

Mastering Nutrition Visit the Study Area in Mastering Nutrition to hear an MP3 chapter summary.

Check Your Understanding LO 21.1 1. Approximately how many

people in the United States are food insecure? a. 11.3 million b. 14.8 million c. 42.2 million d. 16.2 million

LO 21.1 2. Which of the following states in the United States had one of the highest food inse- curity rates between 2013 and 2015? a. Missouri b. Michigan c. North Dakota d. Mississippi

LO 21.2 3. What is the projected world population for 2050? a. 7.8 billion b. 9.7 billion c. 6 billion d. 6.2 billion

LO 21.2 4. Who are the “working poor”? a. Workers classified as low

income by the United States Department of Labor

b. Workers who have no steady employment

c. Workers who are employed but have incomes that fall below the poverty line

d. Workers who earn minimum wage

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LO 21.3 5. The stress of poverty can contribute to overweight and obesity because a. people who are stressed cut

down on exercise in order to get more work done.

b. people who are deal- ing with stress feel some relief when they eat sugary foods, which are high in kilocalories.

c. when a person is stressed, they don’t have the time to choose a healthy snack over a sugary snack.

d. stress reduces the body’s ability to absorb protein.

LO 21.3 6. Infants and children are at higher risk of malnutrition than adults because a. they don’t tend to wash their

hands very often. b. they have a lower body mass

index. c. they have higher nutri-

ent requirements per unit bodyweight.

d. they tend to prefer foods high in added sugar.

LO 21.4 7. Which nutrients are most likely to be used to fortify food? a. Vitamins D, E, and K b. Sodium, potassium, and

chloride c. Magnesium, phosphorus,

and sulfur d. Iron, iodine, and vitamin A

LO 21.4 8. Growing crops for human consumption, rather than to raise meat, could increase kilo- calories available to humans by a. 36 percent. b. 70 percent. c. 25 percent. d. 60 percent.

LO 21.5 9. Which of the following conditions is usually permanent once it occurs? a. Hidden hunger b. Kwashiorkor c. Wasting d. Stunting

LO 21.5 10. Undernutrition increases deaths from pneumonia, diar- rhea, and malaria by a. delaying cognitive

development. b. impairing absorption of

nutrients. c. impairing the immune

system. d. contributing to overweight

and obesity.

Answers 1. (c) About 42.2 million people in the

United States lived in food-insecure households in 2015.

2. (d) Between 2013 and 2015, the six states with the highest food-insecu- rity rates were Mississippi, Louisiana, Arkansas tied with Maine, and Kentucky tied with Alabama.

3. (b) The projected world population for 2050 is 9.7 billion.

4. (c) The working poor include indi- viduals who are employed yet still have incomes below the official pov- erty line.

5. (b) The stress of poverty can con- tribute to overweight and obesity because sugar consumption reduces release of the stress hormone corti- sol, thereby helping reduce feelings of stress, yet foods high in added sugars are typically also high in kilocalories.

6. (c) Infants and children are at higher risk of malnutrition than adults because they have higher nutrient requirements per unit bodyweight.

7. (d) Iron, iodine, and vitamin A are the nutrients most commonly added to fortified foods worldwide.

8. (b) Growing crops for human con- sumption, rather than to raise meat, could increase calories available to humans by 70 percent.

9. (d) Growth stunting is usually per- manent once it occurs.

10. (c) Undernutrition increases deaths from pneumonia, diarrhea, and malaria by impairing the immune system.

Answers to True or False? 1. True. While malnutrition may be

more severe in developing countries, it occurs all over the globe.

2. True. An estimated 795 million people worldwide—more than one in 10—are hungry.

3. False. Even those who have jobs sometimes experience food insecurity.

4. True. Depression among mothers, particularly those in low-income families, has been associated with food insecurity in households.

5. True. The world’s agricultural pro- ducers grow enough food to nourish every man, woman, and child on the planet. The challenge is distributing their products equitably.

6. True. Natural disasters such as droughts, floods, storms, earth- quakes, crop diseases, and insect plagues can create food and water shortages in any country.

7. False. Malnutrition can occur in any- one. Those at greatest risk include pregnant and lactating women, infants and children, and the ill and elderly.

8. False. Fortifying foods can provide numerous nutrients that some popu- lations wouldn’t otherwise obtain.

9. False. There is a clear link in women between food insecurity and over- weight and obesity.

10. True. The number-one cause of brain damage in children is iodine deficiency during preg- nancy. Fortification of salt with iodine reduces the incidence of iodine-deficiency disorders.

Web Resources ■ To learn more about one organization

that is fighting global poverty, visit CARE at www.care.org

■ To find out how the Food and Agriculture Organization of the United Nations leads international efforts to defeat hunger, visit www.fao.org

References 799

■ To learn more about an international children’s group, visit the UNICEF website at www.unicef.org

■ For more about the World Health Organization, visit www.who.org

■ To learn more about how biotech- nology affects food production in  developing countries, visit www.sustaintech.org

■ To find out more about fighting hun- ger and reducing food waste in the United States, visit Feeding America at www.feedingamerica.org

References 1. Food and Agriculture Organization of

the United Nations. 2017. The State of Food Insecurity in the World 2015. Available at www.fao.org. Accessed May 2017.

2. World Health Organization. 2017. Micronu- trient Deficiencies: Vitamin A Deficiency. Avail- able at www.who.int. Accessed March 2017.

3. World Health Organization. Nutrition. Chal- lenges. Available at www.who.int/nutrition/ challenges/en/. Accessed April 2017.

4. The World Bank. 2014. Data. GDP Per Capita ($US). Available at http://data. worldbank.org. Accessed February 2017.

5. USDA. Economic Research Service. 2016. Definitions of Food Security. Available at www.ers.usda.gov. Accessed February 2017.

6. USDA. Economic Research Service. 2016. Food Security in the U.S. Available at www.ers.usda.gov. Accessed February 2017.

7. USDA. Economic Research Service. 2016. Food Security Status of U.S. Households in 2015. Available at www.ers.usda.gov. Accessed February 2017.

8. USDA. Economic Research Service. 2016. How Many People Lived in Food-Insecure Households? Available at www.ers.usda.gov. Accessed February 2017.

9. USDA. 2015. United States Department of Agriculture, Economic Research Service. Key Statistics & Graphics. www.ers.usda.gov. Accessed March 2017.

10. USDA. Economic Research Service. 2016. Very Low Food Security by Household Characteristics. Available at www.ers.usda.gov. Accessed February 2017.

11. Feeding America. 2017. Hunger and Poverty Facts and Statistics. Poverty Statistics in the United States. Available at www.feedingamerica.org/hunger-in- america/impact-of-hunger/hunger-and- poverty/hunger-and-poverty-fact-sheet. html. Accessed May 2017.

12. National Council on Aging. 2017. SNAP and Senior Hunger Facts. Available at https://www.ncoa.org/news/resources- for-reporters/get-the-facts/senior-hunger- facts/. Accessed May 2017.

13. USDA. Economic Research Service. 2016. Food Security Status of U.S. Households in 2015.

14. Feeding America. 2017. African American Hunger Facts. Available at www.feedingamerica .org/hunger-in-america/impact-of-hunger/ african-american-hunger/african-american- hunger-fact-sheet.html. Accessed May 2017.

15. Feeding America. 2017. Latino Hunger Facts. Available at www.feedingamerica.org/ hunger- in-america/impact-of-hunger/latino- hunger/latino-hunger-fact-sheet.html. Accessed May 2017.

16. Feeding America. 2017. Rural Hunger Facts. Available at www.feedingamerica .org/hunger-in-america/impact-of-hunger/ rural-hunger/rural-hunger-fact-sheet.html. Accessed May 2017.

17. USDA. Economic Research Service. 2016. State-Level Prevalence of Food Insecurity. Avail- able at www.ers.usda.gov. Accessed Febru- ary 2017.

18. Chaparro, M. P., S. S. Zaghloul, et al. 2009. Food Insecurity Prevalence Among College Students at the University of Hawai’i at Mānoa. Public Health Nutrition 12(11):2097– 2103. Available at http://scholarspace. manoa.hawaii.edu/handle/10125/20775. Accessed April 2017.

19. Freudenberg, N., L. Manzo, et al. 2011. Food Insecurity at CUNY: Results from a Survey of CUNY Undergraduate Students. New York, NY: Healthy CUNY Initiative, City Uni- versity of New York. Available at https:// www.gc.cuny.edu/CUNY_GC/media/ CUNY-Graduate-Center/PDF/Centers/ Center%20for%20Human%20Environ- ments/cunyfoodinsecurity.pdf. Accessed April 2017.

20. Lindsley, K., and C. King. 2014. Food Inse- curity of Campus-Residing Alaskan College Students. Journal of the Academy of Nutrition and Dietetics 9(114):A94.

21. Maroto, M. E., A. Snelling, et al. (2015). Food Insecurity Among Community Col- lege Students: Prevalence and Association with GRADE POINT AVERAGE. Com- munity College Journal of Research and Practice 39(6):515–526. Available at www.tandfonline .com/doi/abs/10.1080/10668926.2013.85 0758. Accessed April 2017.

22. Patton-López, M. M., Daniel F. Lopezceval- los et al. 2014. Prevalence and Correlates of Food Insecurity Among Students Attending a Midsize Rural University in Oregon. Journal of Nutrition Education and Behavior 46(3):209–214. Available at www. jneb.org/article/S1499-4046(13)00707-0/ abstract?cc=y=. Accessed April 2017.

23. U.S. Census Bureau. 2016. Income and Pov- erty in the United States: 2015. Available at https://www.census.gov/library/publica- tions/2016/demo/p60-256.html. Accessed March 2017.

24. United States Census Bureau. 2015. Poverty Thresholds. Available at https://www.cen- sus.gov/data/tables/time-series/demo/

income-poverty/historical-poverty-thresh- olds.html. Accessed March 2017.

25. U.S. Department of Labor, Bureau of Labor Statistics. 2016. A Profile of the Work- ing Poor, 2014. Available at www.bls.gov. Accessed March 2017.

26. USDA. 2014. Food Deserts. Available at http:// apps.ams.usda.gov. Accessed June 2014.

27. CDC Features. 2012. A Look Inside Food Deserts. Available at https://www.cdc.gov/ features/FoodDeserts/index.html. Accessed March 2017.

28. Whitaker, R. C., S. M. Phillips, et al. 2006. Food Insecurity and the Risks of Depres- sion and Anxiety in Mothers and Behavior Problems in their Preschool-Aged Children. PEDIATRICS 118:e859–e868. Available at http://pediatrics.aappublications.org/. Accessed April 2017.

29. National Coalition for the Homeless. 2009. Mental Illness and Homelessness. Available at www.nationalhomeless.org. Accessed March 2017.

30. Population Reference Bureau. 2016. 2016 World Population Data Sheet. Available at www.prb.org. Accessed March 2017.

31. Food and Agriculture Organization. 2015. The State of Food Insecurity in the World. Under- nourishment around the world in 2015. Available at www.fao.org. Accessed March 2017.

32. Doss, C., Chiara Kovarik et al. 2013. Gender Inequalities in Ownership and Control of Land in Africa. Washington, DC: International Food Policy Research Institute. Available at www. ifpri.org. Accessed March 2017.

33. Agada, M., and E. Igbokwe. 2016. Influ- ence of Food Culture and Practices on Household Food Security in North Central Nigeria. Journal of Food Security 4(2):36–41. http://pubs.sciepub.com/jfs/4/2/2. Accessed May 2017.

34. Ibid. 35. United Nations. 2015. Millenium

Development Goals Report. Available at http:// www.un.org/millenniumgoals/reports. shtml. Accessed March 2017.

36. Petrescu, Ioana M. 2010. The Humanitarian Impact of Economic Sanctions. Available at www.essex.ac.uk. Accessed April 2017.

37. World Food Programme. 2013. Hunger. What Causes Hunger? Available at www.wfp.org. Accessed March 2017.

38. World Hunger Education Service. 2013. 2013 World Hunger and Poverty Facts and Sta- tistics. Available at www.worldhunger.org. Accessed March 2017.

39. Mission 2014: Feeding the World. 2014. Inef- fective/Inadequate Agricultural Practices. Avail- able at www.mit.edu. Accessed March 2017.

40. Dibal, J. M., H. E. Igbadun et al. 2014. Modelling Furrow Irrigation-Induced Erosion on a Sandy Loam Soil in Samaru, Northern Nigeria. International Scholarly Research Notices. Available at https://www.ncbi. nlm.nih.gov/pmc/articles/PMC4897171/. Accessed May 2017.

800 Chapter 21 | Global Nutrition and Malnutrition

41. Mission 2014: Feeding the World. 2014. Inadequate Food Distribution Systems. Available at www.mit.edu. Accessed May 2017.

42. United Nations Environment. 2013. Mini- mizing Food Waste. Available at www.unep.org. Accessed March 2017.

43. Physicians for Social Responsibility. 2017. Climate Change and Famine. http://www.psr.org/ resources/climate-change-and-famine.html. Accessed March 2017.

44. World Food Programme. 2013. Hunger. What Causes Hunger?

45. United States Geological Survey. 2016. USGS Water Science School. Available at https://water.usgs.gov/edu/earthhow- much.html. Accessed May 2017.

46. CNN. 2017. Flint Water Crisis Fast Facts. Available at http://www.cnn.com /2016/03/04/us/flint-water-crisis-fast- facts/. Accessed May 2017.

47. Guarino, Arthur. 2017. The Economic Implications of Global Water Scarcity. Research in Economics and Management 2(1). Available at http://www.scholink.org/ojs/ index.php/rem/article/view/799.

48. United Nations Department of Economic and Social Affairs. 2015. World Population Projected to Reach 9.7 billion by 2050. Avail- able at www.un.org/en/development/ desa/news/population/2015-report.html. Accessed March 2017.

49. Ibid. 50. The World Bank. 2017. #BoldForChange:

World Bank Group Helps Advance Education for Girls and Women. Available at www.worldbank.org. Accessed March 2017.

51. Popkin, B. M., L. S. Adair, et al. 2012. NOW AND THEN: The Global Nutri- tion Transition: The Pandemic of Obesity in Developing Countries. Nutrition Reviews. Available at https://www.ncbi.nlm.nih.gov /pmc/articles/PMC3257829/. Accessed May 2017.

52. WHO. 2017. Nutrition. Double Burden of Malnutrition. Available at www.who.int/ nutrition/double-burden-malnutrition/en/. Accessed May 2017.

53. FAO. 2004. Human Energy Requirements. Report of a Joint FAO/WHO/UNU Expert Consultation. 6. Energy Requirements of Pregnancy. http://www.fao.org/ docrep/007/y5686e/y5686e0a.htm. Accessed March 2017.

54. World Health Organization. 2016. Infant and young child feeding. Fact Sheet. Available at www.who.int/mediacentre/factsheets/ fs342/en/. Accessed May 2017.

55. Mayo Clinic. 2017. Infant and Toddler Health. Available at www.mayoclinic.org/ healthy-lifestyle/infant-and-toddler-health/ in-depth/breastfeeding-nutrition/art- 20046912. Accessed May 2017.

56. Shamim S,. F. Naz et al. 2006. Effect of Weaning Period on Nutritional Status of Children. Journal of the College of Physi- cians and Surgeons (Pakistan) 8:529–531.

Available at https://www.ncbi.nlm.nih. gov/pubmed/16899182. Accessed March 2017.

57. USAID. 2016. Orphans and Vulner- able Children Affected by HIV and AIDS. Available at https://www.usaid.gov/ what-we-do/global-health/hiv-and-aids/ technical-areas/orphans-and-vulnerable- children-affected-hiv. Accessed March 2017.

58. AIDS.gov. 2016. Global HIV/AIDS Over- view. Available at https://www.aids.gov/ federal-resources/around-the-world/ global-aids-overview/. Accessed March 2017.

59. Food Research and Action Center. 2017. Why Low-Income and Food-Insecure People Are Vulnerable to Overweight and Obesity. Available at http://frac.org. Accessed March 2017.

60. Haushofer, J., and E. Fehr, 2014. On the Psychology of Poverty. Science 344(6186):862–867. doi: 10.1126/ science.1232491.

61. Tryon, Matthew, Kimber Stanhope et al. 2015. Excessive Sugar Consumption May Be a Difficult Habit to Break: A View From the Brain and Body. Journal of Clinical Endocrinology and Metabolism. doi: 10.1210/ jc.2014-4353.

62. Second Harvest Food Bank. 2014. How We Work. Available at www.shfb.org. Accessed April 2017.

63. Ibid. 64. USDA. 2016. The Food Assistance Landscape:

FY 2015 Annual Report. Available at www.ers.usda.gov. Accessed March 2017.

65. Food and Agriculture Organization of the United Nations. 2015. The State of Food Insecurity in the World. www.fao.org. Accessed March 2017.

66. Food and Agriculture Organization of the United Nations. 2017. Available at www.fao.org/organicag/oa-faq/oa-faq6/ en/. Accessed April 2017.

67. Khan, Z., C. Midega et al. 2014. Achieving Food Security for One Million Sub-Saharan African Poor Through Push–Pull Innovation by 2020. Available at http://rstb.royalsocietypublishing.org /content/369/1639/20120284.short. Accessed May 2017.

68. Cassidy, E. S., P. C. West et al. 2013. Redefining agricultural yields: from tonnes to people nourished per hectare. Available at http:// iopscience.iop.org/ article/10.1088/ 1748-9326/8/3/034015/meta. Accessed May 2017.

69. Landesa Rural Development Institute. 2012. Land Rights and Agricultural Activity. Available at www.landesa.org. Accessed April 2017.

70. WHO. Media Centre (HELI). 2016. Drinking-water. Available at www.who.int. Accessed March 2017.

71. CDC. 2015. Global Water, Sanitation, & Hygiene (WASH). Available at https:// www.cdc.gov/healthywater/global/ diarrhea-burden.html#five. Accessed April 2017.

72. WHO. Media Centre. 2013. Diarrhoeal Disease. Fact Sheet no. 330. Available at www.who.int. Accessed April 2017.

73. SODIS. 2017. SODIS Method. Available at www.sodis.ch/methode/index_EN. Accessed April 2017.

74. WHO. 2017. Media Centre. Sanitation. Available at www.who.int/mediacentre/ factsheets/fs392/en/. Accessed May 2017.

75. Bill and Melinda Gates Founda- tion. 2014. Reinvent the Toilet Chal- lenge. www.gatesfoundation.org/ What-We-Do/Global-Development/ Reinvent-the-Toilet-Challenge

76. CDC Food Fortification Initiative. 2017. Global Progress. Available at www.ffinetwork.org /global_progress/index.php. Accessed April 2017.

77. United Nations Educational, Scientific and Cultural Organization. 2016. Global Educa- tion Monitoring Report. Education for People and Planet. Available at http://en.unesco.org/ gem-report/. Accessed May 2017.

78. Earth Policy Institute. 2011. Education Leads to Lower Fertility and Increased Prosperity. Available at www.earth-policy.org/data_ highlights/2011/highlights13. Accessed April 2017.

79. United Nations Educational, Scientific and Cultural Organization. 2016. Global Educa- tion Monitoring Report. Education for People and Planet.

80. World Food Programme. 2017. Overview. Available at www.wfp.org. Accessed April 2017.

81. UNICEF. 2013. UNICEF in Emergencies and Humanitarian Action. UNICEF’s Role in Humanitarian Action. Available at www.unicef.org. Accessed April 2017.

82. Heifer International. 2014. About Heifer International. Available at www.heifer.org. Accessed April 2017.

83. Peace Corps. 2016. Global Initiatives. Avail- able at https://www.peacecorps.gov/ about/global-initiatives/. Accessed April 2017.

84. Morley, J.E. 2016. Merck Manual Professional Version. Overview of Undernutrition. Available at www.merckmanuals.com/professional/ nutritional-disorders/undernutrition/ overview-of-undernutrition#v882492. Accessed April 2017.

85. American Psychological Association. Effects of Poverty, Hunger and Home- lessnes on Children and Youth. 2017. What are the effects of hunger and undernutrition on child development? Available at www.apa.org /pi/families/poverty.aspx. Accessed April 2017.

86. World Health Organization. 2016. Global Database on Child Growth and Malnutri- tion Joint Child Malnutrition Estimates– Levels and trends (2016 edition) UNICEF / WHO / World Bank Group. Available at www.who.int/

nutgrowthdb/estimates2015/en/. Accessed April 2017.

87. Ibid. 88. Ibid. 89. Chen, Z. P., and B. S. Hetzel. 2017.

Cretinism Revisited. Clinical Endocrinology and Metabolism doi: http://dx.doi.org/ 10.1016/j.beem.2009.08.014.

90. World Health Organization. 2017. Micro- nutrient Deficiencies: Iodine deficiency disorders. Available at www.who.int. Accessed May 2017.

91. World Health Organization. 2016. Global Database on Child Growth and Malnutrition Joint Child Malnutrition Estimates–Levels

and trends (2016 edition). UNICEF / WHO / World Bank Group.

92. World Health Organization. 2017. Water Sanitation Health. Water-Related Diseases. Diar- rhoea. Available at www.who.int. Accessed April 2017.

93. World Health Organization. Media Centre. 2017. Children: Reducing Mortality. Available at www.who.int. Accessed April 2017.

94. Ibid. 95. Wessells, K. R. and Kenneth H. Brown.

2012. Estimating the Global Prevalence of Zinc Deficiency: Results Based on Zinc Availability in National Food Supplies and the Prevalence of Stunting. Public Library of Science.

Available at https://doi.org/10.1371/ journal.pone.0050568. Accessed May 2017.

96. World Health Organization. 2017. Micro- nutrient Deficiencies: Iron-Deficiency Anaemia. Available at www.who.int. Accessed March 2017.

97. World Health Organization. 2017. Feto- Maternal Nutrition and Low Birth Weight. Available at www.who.int. Accessed March 2017.

98. The Mother and Child Health and Educa- tion Trust. 2017. Impact of Malnutrition. Avail- able at http://motherchildnutrition.org/ malnutrition/about-malnutrition/ impact-of-malnutrition.html.

References 801

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Appendices A-1

Appendix A Metabolism Pathways and Biochemical Structures  A-3

Appendix B Calculations and Conversions  B-1

Appendix C U.S. Exchange Lists for Meal Planning  C-1

Appendix D Organizations and Resources  D-1

Appendices

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When learning about the science of nutrition, it is important to understand basic principles of metabolism and to know the molecular structures of important nutrients and molecules. Chapter 8 of the text provides a detailed discussion of the major metabolic processes that occur within the body. This appendix gives additional information and detail on several metabolism pathways and biochemical structures of importance.

Appendix A Metabolism Pathways and Biochemical Structures

Appendix A | Metabolism Pathways and Biochemical Structures A-3

A-4 Appendix A | Metabolism Pathways and Biochemical Structures

Metabolism Pathways

▲ Figure A.1 Glycolysis Pathway.

C C C C C C

C C C C C C

C C C C C C

C C C C C C

C C C C C C

C C C

C C C

C C C

C C C

C C C

C C C

P

P

PP

P

P

P

P

C C C P

P

P

P

P

P

P

H2O H2O

NAD+

H+ 2 2

2

TCA Cycle

Acetyl CoA

Glycolysis

Electron Transport Chain

Glucose

ATP

ADP

ATP

ADP

ATP

ADP

ATP

ADP

Fructose 1,6-bisphosphate

Glyceraldehyde 3-phosphateDihydroxyacetone

phosphate

1,3-bisphosphoglycerate

2-phosphoenolpyruvate

Pyruvate

Glucose 6-phosphate

Fructose 6-phosphate

A phosphate group is added to glucose to form glucose 6-phosphate. ATP is used in this reaction.

1

One phosphate is added to fructose 6-phosphate to create fructose 1,6-bisphosphate. 1,6 indicates where the phosphates were added to the carbon chain. ATP is used in this reaction.

3

Fructose 1,6-bisphosphate is broken down to glyceraldehyde 3-phosphate (G3P) and dihydroxyacetone phosphate (DHAP).

4

DHAP is rearranged to create another molecule of G3P. 5

One phosphate is added to each G3P to form two molecules of 1,3-bisphosphoglycerate. Two molecules of NADH+ + H+ are formed in the process.

6

In the next three steps, two molecules of 2-phosphoenolpyruvate, two ATP, and two molecules of water are formed.

7, 8, 9

Glucose 6-phosphate is rearranged to form a new compound called fructose 6-phosphate. 2

Two molecules of pyruvate and two molecules of ATP are formed in the final step of glycolysis.

10

ATP

ADP

ATP

ADP

NADH

Appendix A | Metabolism Pathways and Biochemical Structures A-5

▲ Figure A.3 TCA Cycle.

TCA Cycle

PyruvateCC C

Acetyl CoACC

C

C

C C

C

C

OOH

OOHHO

OOH

C

C

C C

C

C

OOH

OOH

OOH

OH

C

C

C

C

C

OOH

C

C

C

C

OOH

C O2

C

C

C

OOH

C OOH O

C

C

C

OOH

OH

C OOH

C

C C

C

C

OOH

O

C OOH

C

C OOH OOH

O

1

2

3

46

7

8 Oxaloacetate

Isocitrate

c-ketoglutarate

Succinyl CoA Succinate

Fumarate

Malate

Citrate

CoA

CoA

CoA

CoA CoA

GTP GDP

Acetyl CoA

TCA Cycle

Glycolysis

Electron Transport Chain

5

H2O

H2O

H2O

Acetyl CoA binds with oxaloacetate to form citrate in the first reaction in the TCA cycle. The CoA is released in this step.

1

A molecule of water is added to citrate to form isocitrate in step 2.

2

c-ketoglutarate loses a carbon to CO2 and gains a CoA to form succinyl CoA. NADH + H+ is formed in the process.

4

CoA is removed from succinyl CoA, and a molecule of water is added forming succinate. GTP is produced.

5

Succinate is oxidized to fumarate and FADH2 is produced.

6

Fumarate is converted to malate with the addition of water.

7

Malate regenerates oxaloacetate to begin the cycle again. NADH + H+ is produced.

8

Isocitrate loses a carbon to CO2 to form c-ketoglutarate. One NADH + H+ is produced.

3

H+

NADH

H+

NADH

H+

NADH

FADH2 NAD+

NAD+

NAD+

FAD

+

C O2+

C

C

OOH

▲ Figure A.2 Acetyl CoA Pathway.

TCA Cycle

Glycolysis

Electron Transport Chain

Two molecules of pyruvate each lose a carbon and gain a molecule of coenzyme A.

1

Coenzyme A attaches to the remaining two carbons to form acetyl CoA.

2

Acetyl CoA

2 Pyruvate Lactate

CoA

CoA CoA

CoA 2 Acetyl CoA

2 2

H+ NADH

2 2

H+ NADH

NAD+2

NAD+2C C C

C C

C C

C C C

O2C O2C

A-6 Appendix A | Metabolism Pathways and Biochemical Structures

▲ Figure A.4 Electron Transport Chain.

ADP P

Hydrogen ions with high-energy electrons are delivered to the inner mitochondrial membrane from the TCA cycle by NADH + H+ and FADH2.

1 As the protein complexes pass the electrons down the electron transport chain, hydrogen ions cross the mitochondrial membrane.

2 Hydrogen ions are forced back across the membrane through ATP synthase to produce ATP during oxidative phosphorylation.

3

H+ NADH

TCA Cycle

Glycolysis

Electron Transport Chain

Inner mitochondrial membrane

Outer mitochondrial membrane

Cytosol

Matrix

Outer membrane

Inner membrane

Mitochondrial matrix

High H+ concentration

Low H+ concentration

1

2

ATP

ATP synthase Protein

complexes 3½ O2 +

+ H2O

H+ H+ H+ H+ H+ H+ H+

H+ H+

H+ H+

H+

H+

H+

H+ H+

e- e-

e- e-

e- e-

Acetyl CoA

NAD+ FAD

FADH2

Intermem- brane space

Appendix A | Metabolism Pathways and Biochemical Structures A-7

▲ Figure A.5 Products of Metabolic Pathways.

Glycolysis

Electron Transport Chain

TCA Cycle

Glucose Fructose 1,6-bisphosphate

ATP ATP2 –2

ATP4

Glyceraldehyde 3-phosphate 1,3-bisphosphoglyceric acid 2

1,3-bisphosphoglyceric acid Pyruvic acid

ATP 4

GTP2GTP 2

Metabolic reaction

Sources of energy use and production in the different metabolic pathways Reaction by-product

Number used

Number produced

Net usage/ production

Pyruvic acid Acetyl CoA 2

Isocitrate Succinyl CoA 4 via electron transport chain

via electron transport chain

4

Succinyl CoA Succinate

Succinate Fumarate 2 via electron transport chain

2

Malate Oxaloacetate 2 via electron transport chain

2

ATP4 – 2 = 2 1 2 × 1 = 2

ATP2 × 2 = 4 or 2 × 3 = 6

ATP8 × 3 = 248 3

ATP2 × 1 = 2

ATP2 × 2 = 4

2 1

ATPBalance of energy from the oxidation of one unit of glucose: 36 to 38

2 2

Energy balance sheet for glucose oxidation

Reaction by-product

Number of ATP produced per product

Number produced

Net usage/ production

2 2 to 3

ATP

GTP

a

b

Acetyl CoA

via electron transport chain

from glycolysis

from TCA cycle

FADH2

FADH2 FADH2

2 H+ NADH +

2 H+ NADH +

H+ NADH +

H+ NADH +

H+ NADH +H+ NADH +

H+ NADH +H+ NADH +

H+ NADH +

H+ NADH +

A-8 Appendix A | Metabolism Pathways and Biochemical Structures

▲ Figure A.6 Using Fat for Energy.

CoA

Acetyl CoA

TCA Cycle

Glycolysis

Electron Transport Chain

Triglycerides from the diet and adipose tissue undergo lipolysis to yield free fatty acids and glycerol. Hormone- sensitive lipase stimulates the reaction.

1

Glycerol is first converted to DHAP before it can enter anaerobic glycolysis to be converted to pyruvate. The first step requires ATP.

2

During beta-oxidation, a molecule of Coenzyme A is attached to the end of a fatty acid. The two end carbons plus CoA are then cleaved off and converted to acetyl CoA, reducing NAD+ to NADH + H+ and FAD to FADH2.

3

This aerobic process repeats itself until all the fatty acids have been converted to acytyl CoA. The acetyl CoA formed enters the TCA cycle.

4

DHAPCC C

CC C G3P

PyruvateCC C

CC Acetyl CoA

CC C C

C C C

C C

Fatty acid Glycerol

C C C

C

CoA

CoA

C C C

C CoA

C C CoA

Shorter fatty acid

Beta-oxidation

Lipolysis

P

P

ATP ADP

C CH

H

O

O Fatty acid

C CH

H O

O Fatty acid

C CH

O

O Fatty acid

Triglyceride

NAD+

H+

NADH

FAD FADH2

C C CoA

▲ Figure A.7 Ketone Bodies.

TCA Cycle

Glycolysis

Electron Transport Chain

+ +C C

O

CoA

Acetyl CoA

Ketogenesis

C C

O

CoA

CoA CoA

Acetyl CoA

H2O

C OOHC

OH

C C

C OOHC

O

C C

Acetoacetate

C C

O

C

Acetone

Beta-hydroxybutyrate

Acetyl CoA

O2C

Ketone bodies are produced in the mitochondria of the liver through ketogenesis from excess acetyl CoA.

1

Acetoacetate can be reduced tobeta-hydroxybutyrate using NADH + H+, producing NAD+, or it can form acetone after a carbon is removed, creating carbon dioxide.

2NAD+

H+ NADH

Appendix A | Metabolism Pathways and Biochemical Structures A-9

▲ Figure A.8 Amino Acid Structures.

C

H

H3N +

CH2

COOH

COO–

Aspartate (Asp)

C

H

H3N +

CH2

CH2

COOH

COO–

Glutamate (Glu)

C

C NH2 +

H

H3N +

CH2

CH2

CH2

NH

NH2

COO–

Arginine (Arg )

C

NH3 +

H

H3N +

CH2

CH2

CH2

CH2

COO–

Lysine (Lys )

C

H

H3N +

CH2

COO–

Histidine (His)

NH

NH+

C

H

H3N +

CH2

OH

COO–

Serine (Ser)

C

H

H3N +

CH

CH3HO

COO–

Threonine (Thr)

C

H

H3N +

CH2

C

NH2O

COO–

Asparagine (Asn)

C

H

H3N +

CH2

C

NH2O

CH2

COO–

Glutamine (Gln)

C

H

H3N +

CH3

COO–

Alanine (Ala )

C

H

H3N +

CH

CH2

CH3

H3C

COO–

Isoleucine (Ile)

C

H

H3N +

CH2

CH

CH3H3C

COO–

Leucine (Leu)

C

H

H3N +

CH

CH3H3C

COO–

Valine (Val)

C

H

H3N +

H

COO–

Glycine (Gly)

Amino Acids

Amino acids with acidic side chains

Amino acids with basic

side chains

Amino acids with carbon- and

hydrogen-containing side chains

Amino acids with hydroxyl (OH)

side chains

Amino acids with amine (NH2)

side chains

Biochemical Structures

Amino Acid Structures Amino acids all have the same basic core but differ in their side chains. The following amino acids have been classified according to their specific type of side chain.

A-10 Appendix A | Metabolism Pathways and Biochemical Structures

Vitamin Structures and Coenzyme Derivatives Many vitamins have common names (e.g., vitamin C, vitamin E) as well as scientific des- ignations (e.g., ascorbic acid and α-tocopherol). Most vitamins are found in more than one chemical form. Many of the vitamins illustrated here have an active coenzyme form; review both the vitamin and coenzyme structures and see if you can locate the “core vitamin” structure within each of the coenzymes. The vitamins found in food or supplements are not always in the precise chemical form needed for metabolic activity, and therefore the body often has to modify the vitamin in one way or another. For example, many of the B vitamins are phosphorylated, meaning that they have a phosphate group attached.

C

H

H3N +

CH2

COO–

Phenylalanine (Phe)

C

H

H3N +

CH2

COO–

Tryptophan (Trp)

C

H

H3N +

CH2

OH

COO–

Tyrosine (Tyr)

NH

C

H

H3N +

CH2

SH

COO–

Cysteine (Cys)

C

H

H3N +

CH2

CH2

S

CH3

COO–

Methionine (Met)

C

H

H2N +

CH2CH2

CH2

COO–

Proline (Pro)

Amino Acids

Amino acids with aromatic

(ring) side chains

Amino acids with sulfur-containing

side chains

Amino group, after losing one hydrogen,

forms a ring structure

▲ Figure A.8 Amino Acid Structures (Continued).

Appendix A | Metabolism Pathways and Biochemical Structures A-11

Vitamin Form

Vitamin A

Precursor (converted to vitamin by body)

Vitamin

Active form

d-carotene

Cholecalciferol (vitamin D3)

In liver is converted to

In kidney is converted to

Retinol (alcohol form)

Retinal (aldehyde form)

Vitamin D

Vitamin E

Vitamin K

CH3

CH3H3C

CH3

CH3H3C CH3 CH3

CH3 CH3

CH3

CH3H3C CHO

COOH

Retinoic acid (acid form)

CH3

CH3H3C CH3 CH3

CH3 CH3

CH3

CH3 CH2OH H3C

CH3 CH3

c-tocopherol

CH3

CH2

H3C

HO

CH3

CH3CH3 CH3

Calcitriol (1,25-dihydroxycholecalciferol)

CH3

OH OH

OH

CH2

H3C

HO

CH3

Calcidiol (25-hydroxycholecalciferol)

CH3

CH2

H3C

HO

CH3

CH3 H3C

CH3

CH3

CH3

CH3

CH3 CH3

HO

O

Menaquinone (from bacterial synthesis) CH3 CH3 CH3

CH3

CH3

O

O

CH3 CH3 CH3 CH3 CH3

Phylloquinone (from plant source)

CH3

CH3 CH3 CH3

CH3

O

O

CH3 Menadione (synthetic form)

CH3

O

O

▲ Figure A.9 Fat-Soluble Vitamins.

A-12 Appendix A | Metabolism Pathways and Biochemical Structures

Thiamin

Vitamin Form

Coenzyme Form

S

N

N

N CH2 CH3

Amine Thiazole

CH2 CH2 OHH3C NH2

+

Thiamin pyrophosphate

Phosphate groups

SN

N CH2 CH3

CH2NH2 CH2 O P O P

O O

OH OH

O–

N +

H3C

Riboflavin

Vitamin Form

Coenzyme Form

N

N H O

N

N

H3C CH3

CH2 CH

OH

CH2OHCH

OH

CH

OH

Riboflavin

Flavin adenine dinucleotide (FAD)

Pyrophosphates

FMN AMP

N

N H O

N

N

H3C CH3

CH2 CH

OH

CH2CH

OH

CH

OH

O P

O

CH2O OP

O

O– O–

N

NN

N

NH2

H H

O

H H

OH OH

O

O

▲ Figure A.10 Water-Soluble Vitamins and Their Coenzymes.

Appendix A | Metabolism Pathways and Biochemical Structures A-13

Niacin

Vitamin Form

Coenzyme Form

Nicotinic acid N

COOH

Nicotinamide N

CONH2

or

Nicotinamide adenine dinucleotide (NAD+)

Nicotinamide adenine dinucleotide phosphate (NADP+)

N

CONH2

CH2

CH2

+

OHHO

N

N N

N

NH2

OO

OHHO

OO

P

O

O–O

P O–O

N

CONH2

CH2

CH2

+

OHHO

N

N N

N

NH2

OO

OPO3 –2HO

OO

P

O

O–O

P O–O

Pantothenic acid

Vitamin Form

Coenzyme Form

HO CH2 CH2 CH2CH

CH3

H3C OH

C NH

O

Pantothenic acid

C O–

O

C

CH2 CH2

O O–P

O–

O OP

O

O–

O CH2 CH2NHP

O

O–

Coenzyme A

CH3

H3C

C

OH

CH

O

C

O

C CH2 CH2NH SH

H H

O

H H

O OH

Adenine

▲ Figure A.10 Water-Soluble Vitamins and Their Coenzymes. (Continued)

A-14 Appendix A | Metabolism Pathways and Biochemical Structures

Biotin

Vitamin Form

O

NHHN

CH

C

H

HC

S H2C C CH2 CH2 CH2 CH2

O

C OH

Vitamin B6

Vitamin Form

Coenzyme Form

N

Pyridoxine (PN)

CH2OH

CH2OH

H3C

HO

N

Pyridoxal (PL)

CHO

CH2OH

H3C

HO

N

Pyridoxamine (PM)

CH2NH2

CH2OH

H3C

HO

N

Pyridoxine 5′ phosphate (PNP)

CH2OH

CH2

H3C

HO

N

Pyridoxamine 5′ phosphate (PMP)

CH2NH2

CH2

H3C

HOO P OH

O

O–

N

Pyridoxal 5′ phosphate (PLP)

CHO

CH2

H3C

HO O OHP

O

O–

O OHP

O

O–

C

O

OH

C

O

OH

HN N

N N

H2N

OH

CH2 CHCNH NH

CH2

CH2

O

Tetrahydrofolate

H

H

H

Folate

Vitamin Form

Coenzyme Form

C

O

OH

C

O

OH

N N

N N

H2N

CH2 CHCNH NH

CH2

CH2

O

Pteridine PABA

Glutamate

OH

▲ Figure A.10 Water-Soluble Vitamins and Their Coenzymes. (Continued)

Appendix A | Metabolism Pathways and Biochemical Structures A-15

Vitamin B12

Vitamin Form

C

O

H2N H2C H2C CH3

CH3

CH3

CH3

CH3

CH3

C

O

CH2CH2

CH2

NH2

C

O

CH2 NH2

C

O

CH2CH2

CH3 CH3

NH2 C

O

H2N H2C

C

O

H2N H2C

H2CH2C

H3C

COH

H

H3C

H3C N N

NN

Co

CN

N

CH2

C

O

H

HO

O

P

O HO

O–

O

N

N

Cyanocobalamin

C

O

H2N H2C H2C CH3

CH3

CH3

CH3

CH3

CH3

C

O

CH2CH2

CH2

NH2

C

O

CH2 NH2

C

O

CH2CH2

CH3 CH3

NH2 C

O

H2N H2C

C

O

H2N H2C

H2CH2C

H3C

COH

H

H3C

H3C N N

NN

Co

CH3

N

CH2

C

O

H

HO

O

P

O HO

O–

O

N

N

Methylcobalamin

Vitamin C

Vitamin Form

Oxidation

2 H+

2 H+ Reduction

Ascorbic acid Dehydroascorbic acid

CH

H H

HO CHHO

CH2OH

O

HO

HO

O

CH2OH

O

O

O

O

Choline

Vitamin Form

+N

CH3

H3C CH2 CH2OH

CH3

▲ Figure A.10 Water-Soluble Vitamins and Their Coenzymes. (Continued)

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Appendix B | Calculations and Conversions B-1

Calculation and Conversion Aids

Commonly Used Metric Units millimeter (mm) : one-thousandth of a meter (0.001)

centimeter (cm) : one-hundredth of a meter (0.01)

kilometer (km) : one-thousand times a meter (1,000)

kilogram (kg) : one-thousand times a gram (1,000)

milligram (mg) : one-thousandth of a gram (0.001)

microgram (mg) : one-millionth of a gram (0.000001)

milliliter (ml) : one-thousandth of a liter (0.001)

Conversion Factors Use the following table to convert U.S. measurements to metric equivalents:

Original Unit Multiply By To Get ounces (avdp) 28.3495 grams ounces 0.0625 pounds pounds 0.4536 kilograms pounds 16 ounces grams 0.0353 ounces grams 0.0022 pounds kilograms 2.2046 pounds liters 1.8162 pints (dry) liters 2.1134 pints (liquid) liters 0.9081 quarts (dry) liters 1.0567 quarts (liquid) liters 0.2642 gallons (U.S.) pints (dry) 0.5506 liters pints (liquid) 0.4732 liters quarts (dry) 1.1012 liters quarts (liquid) 0.9463 liters gallons (U.S.) 3.7854 liters millimeters 0.0394 inches centimeters 0.3937 inches centimeters 0.0328 feet inches 25.4000 millimeters inches 2.5400 centimeters inches 0.0254 meters feet 0.3048 meters meters 3.2808 feet meters 1.0936 yards cubic feet 0.0283 cubic meters cubic meters 35.3147 cubic feet cubic meters 1.3079 cubic yards cubic yards 0.7646 cubic meters

International Units Some vitamin supplements may report vitamin content as Inter- national Units (IU).

To convert IU to:

❯ Micrograms of vitamin D (cholecalciferol), multiply the IU value by 0.025.

❯ Milligrams of vitamin E (alpha-tocopherol), multi- ply the IU value by 0.67 if vitamin E is from natural sources. Multiply the IU value by 0.45 if vitamin E is from synthetic sources.

❯ Vitamin A: 1 IU = 0.3 mg retinol or 0.3 mg RAE or 0.6 mg beta-carotene

Retinol Activity Equivalents Retinol activity equivalents (RAE) are a standardized unit of measure for vitamin A. RAE account for the various differences in bioavailability from sources of vitamin A. Many supplements will report vitamin A content in IU, as shown above, or in retinol equivalents (RE).

1 mg RAE = 1 mg retinol

12 mg beta@carotene

To calculate RAE from the RE value of vitamin carotenoids in foods, divide RE by 2. Divide the amount of beta-carotene by 12 to convert to RAE.

For vitamin A supplements and foods fortified with vitamin A, 1 RE = 1 RAE.

Folate Folate is measured as dietary folate equivalents (DFE). DFE accounts for the different factors affecting bioavailability of folate sources.

1 mg DFE = 1 mg food folate 0.6 mg folate from fortified foods 0.5 mg folate supplement taken on an empty stomach 0.6 mg folate as a supplement consumed with a meal

To convert micrograms of synthetic folate, such as that found in supplements or fortified foods, to DFE:

mg synthetic folate * 1.7 = mg DFE

For naturally occurring food folate, such as spinach, each micro- gram of folate equals 1 microgram DFE:

mg folate = mg DFE

Appendix B Calculations and Conversions

B-2 Appendix B | Calculations and Conversions

Niacin Niacin is measured as niacin equivalents (mg NE). NE reflects the amount of preformed niacin in foods or the amount that can be formed from a food’s content of the amino acid niacin.

To calculate mg NE from a meal: If you know the tryptophan and preformed niacin in a meal:

(tryptophan * 1,000 , 60) + preformed niacin = mg NE If you know the total amount of protein in a meal but not the

tryptophan content: (0.011 * g of protein) * 1,000 , 60 + preformed niacin = mg NE

Length: U.S. and Metric Equivalents 1�4 inch = 0.6 centimeters

1 inch = 2.5 centimeters 1 foot = 0.3048 meter

30.48 centimeters 1 yard = 0.9144 meter

1 millimeter = 0.03937 inch 1 centimeter = 0.3937 inch 1 decimeter = 3.937 inches

1 meter = 39.37 inches 1.094 yards

1 micrometer = 0.00003937 inch

Weights and Measures Food Measurement Equivalencies from U.S. to Metric

Capacity 1�5 teaspoon = 1 milliliter 1�4 teaspoon = 1.23 milliliters 1�2 teaspoon = 2.5 milliliters

1 teaspoon = 5 milliliters 1 tablespoon = 15 milliliters 1 fluid ounce = 30 milliliters

1�4 cup = 59 milliliters 1�3 cup = 79 milliliters 1�2 cup = 118 milliliters

1 cup = 237 milliliters 1 pint (2 cups) = 473 milliliters

1 quart (4 cups) = 0.95 liter 1 liter (1.06 quarts) = 1,000 milliliters 1 gallon (4 quarts) = 3.79 liters

Weight 0.035 ounce = 1 gram

1 ounce = 28 grams 1�4 pound (4 ounces) = 113 grams 1 pound (16 ounces) = 454 grams

2.2 pounds (35 ounces) = 1 kilogram

U.S. Food Measurement Equivalents 3 teaspoons = 1 tablespoon

1�2 tablespoon = 11�2 teaspoons 2 tablespoons = 1�8 cup 4 tablespoons = 1�4 cup

5 tablespoons + 1 teaspoon = 1�3 cup 8 tablespoons = 1�2 cup

10 tablespoons + 2 teaspoons = 2�3 cup 12 tablespoons = 3�4 cup 16 tablespoons = 1 cup

2 cups = 1 pint 4 cups = 1 quart 2 pints = 1 quart

4 quarts = 1 gallon

Volumes and Capacities 1 cup = 8 fluid ounces

1�2 liquid pint 1 milliliter = 0.061 cubic inch

1 liter = 1.057 liquid quarts 0.908 dry quart 61.024 cubic inches

1 U.S. gallon = 231 cubic inches 3.785 liters 0.833 British gallon 128 U.S. fluid ounces

1 British Imperial gallon = 277.42 cubic inches 1.201 U.S. gallons 4.546 liters 160 British fluid ounces

1 U.S. ounce, liquid or fluid = 1.805 cubic inches 29.574 milliliters 1.041 British fluid ounces

1 pint, dry = 33.600 cubic inches 0.551 liter

1 pint, liquid = 28.875 cubic inches 0.473 liter

1 U.S. quart, dry = 67.201 cubic inches 1.101 liters

1 U.S. quart, liquid = 57.75 cubic inches 0.946 liter

1 British quart = 69.355 cubic inches 1.032 U.S. quarts, dry 1.201 U.S. quarts, liquid

Appendix B | Calculations and Conversions B-3

Temperature Scales

To Convert Fahrenheit to Celsius [(°F-32) * 5]/9

1. Subtract 32 from °F 2. Multiply (°F – 32) by 5, then divide by 9

To Convert Celsius to Fahrenheit [(°C * 9)/5] + 32

1. Multiply °C by 9, then divide by 5 2. Add 32 to (°C * 9/5)

Energy Units 1 kilocalorie (kcal) = 4.2 kilojoules 1 megajoule (MJ) = 239 kilocalories

1 kilojoule (kJ) = 0.24 kcal 1 gram carbohydrate = 4 kcals

1 gram fat = 9 kcals 1 gram protein = 4 kcals

Temperature Standards °Fahrenheit °Celsius

Body temperature 98.6° 37°

Comfortable room temperature 65–75° 18–24°

Boiling point of water 212° 100°

Freezing point of water 32° 0°

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Appendix C | U.S. Exchange Lists for Meal Planning C-1

Starch One starch choice has 15 grams of carbohydrate, 3 grams of protein, 1 gram of fat, and 80 calories.

Icon Key

= Good source of fiber ! = Extra fat

= High in sodium

Appendix C U.S. Exchange Lists for Meal Planning

Food Serving Size Bread

Bagel ................................................................. 1⁄4 large bagel (1 oz)

! Biscuit ...............................................................1 biscuit (21⁄2 inches across)

Breads, loaf-type

white, whole-grain, French, Italian, .................. pumpernickel, rye, sourdough, unfrosted

raisin or cinnamon

1 slice (1 oz)

reduced-calorie, light .....................................2 slices (11⁄2 oz)

Breads, flat-type (flatbreads)

chapatti .........................................................1 oz

ciabatta .........................................................1 oz

naan ..............................................................31⁄4 inch square (1 oz)

pita (6 inches across) .....................................1⁄2 pita

roti .................................................................1 oz

✓ sandwich flat buns, whole-wheat ...................1 bun, including top and bottom 11⁄2 oz)

! taco shell .......................................................2 taco shells (each 5 inches across)

tortilla, corn....................................................1 small tortilla (6 inches across)

tortilla, flour (white or whole-wheat) ................1 small tortilla (6 inches across) or 1⁄3 large tortilla (10 inches across)

Cornbread .........................................................13⁄4–inch cube (11⁄2 oz)

English muffin ....................................................1⁄2 muffin

Hot dog bun or hamburger bun .........................1⁄2 bun (3⁄4 oz)

Pancake ............................................................1 pancake (4 inches across, 1⁄4 inch thick)

Roll, plain ...........................................................1 small roll (1 oz)

! Stuffing, bread ...................................................1⁄3 cup

Waffle ................................................................1 waffle (4-inch square or 4 inches across)

Cereals Bran cereal (twigs, buds, or flakes) ....................1⁄2 cup

Cooked cereals (oats, oatmeal) ..........................1⁄2 cup

Granola cereal ...................................................1⁄4 cup

Grits, cooked .....................................................1⁄2 cup

Muesli ................................................................1⁄4 cup

Puffed cereal .....................................................11⁄2 cups

Shredded wheat, plain .......................................1⁄2 cup

Food Serving Size Sugar-coated cereal ..........................................1⁄2 cup

Unsweetened, ready-to-eat cereal .....................3⁄4 cup

Grains (Including Pasta and Rice) Unless otherwise indicated, serving sizes listed are for cooked grains.

Barley ................................................................1⁄3 cup

Bran, dry

oat.................................................................1⁄4 cup

wheat ............................................................1⁄2 cup

Bulgur ...............................................................1⁄2 cup

Couscous ..........................................................1⁄3 cup

Kasha ................................................................1⁄2 cup

Millet ..................................................................1⁄3 cup

Pasta, white or whole-wheat (all shapes and sizes) ..............................................................1⁄3 cup

Polenta ..............................................................1⁄3 cup

Quinoa, all colors ...............................................1⁄3 cup

Rice, white, brown, and other colors and types .... 1⁄3 cup

Tabbouleh (tabouli), prepared.............................1⁄2 cup

Wheat germ, dry ................................................3 Tbsp

Wild rice ............................................................1⁄2 cup

Starchy Vegetables All of the serving sizes for starchy vegetables on this list are for cooked

vegetables.

Breadfruit...........................................................1⁄4 cup

Cassava or dasheen ..........................................1⁄3 cup

Corn ..................................................................1⁄2 cup

on cob ...........................................................4- to 41⁄2–inch piece (1⁄2 large cob)

Hominy ..............................................................3⁄4 cup

Mixed vegetables with corn or peas ...................1 cup

Marinara, pasta, or spaghetti sauce ...................1⁄2 cup

Parsnips ............................................................1⁄2 cup

Peas, green .......................................................1⁄2 cup

Plantain .............................................................1⁄3 cup

Potato

baked with skin .............................................1⁄4 large potato (3 oz)

boiled, all kinds ..............................................1⁄2 cup or 1⁄2 medium potato (3 oz)

! mashed, with milk and fat ..............................1⁄2 cup

Source: From Choose Your Foods: Exchange Lists for Diabetes. © Academy of Nutrition and Dietetics. Adapted and reprinted with permission.

C-2 Appendix C | U.S. Exchange Lists for Meal Planning

Food Serving Size French-fried (oven-baked)* .............................1 cup (2 oz)

Pumpkin puree, canned, no sugar added ..........3⁄4 cup

Squash, winter (acorn, butternut) .......................1 cup

Succotash .........................................................1⁄2 cup

Yam or sweet potato, plain ....................................1⁄2 cup (31⁄2 oz)

Crackers and Snacks Note: Some snacks are high in fat. Always check food labels.

Crackers

animal ................................................................8 crackers

crispbread ...................................................2–5pieces 3⁄4 oz

graham, 21�2@inch square ................................3 squares

nut and rice ...................................................10 crackers

oyster ............................................................20 crackers

! round, butter-type ..........................................6 crackers

saltine-type ....................................................6 crackers

! sandwich-style, cheese or peanut butter filling ...............................................................3 crackers

whole-wheat, baked ......................................5 regular 11⁄2–inch squares or 10 thins (3⁄4 oz)

Granola or snack bar .........................................1 bar (3⁄4 oz)

Matzoh, all shapes and sizes .............................(3⁄4 oz)

Melba toast .......................................................4 pieces (each about 2 by 4 inches)

Popcorn

Food Serving Size no fat added ................................................3 cups

!! with butter added ........................................3 cups

Pretzels .............................................................3⁄4 oz

Rice cakes .........................................................2 cakes (4 inches across)

Snack chips

baked (potato, pita) .......................................about 8 chips (3⁄4 oz)

!! regular (tortilla, potato) ..................................about 13 chips (1 oz)

! count as 1 starch choice + 1 fat choice (1 starch choice plus 5 grams of fat)

!! count as 1 starch choice + 2 fat choices (1 starch choice plus 10 grams of fat)

Note: For other snacks, see the Sweets, Desserts, and Other Carbohydrates list, page C-4.

Beans, Peas, and Lentils The choices on this list count as 1 starch choice + 1 lean protein choice.

Baked beans, canned .....................................1⁄3 cup

Beans (black, garbanzo, kidney, lima, navy, pinto, white), cooked or canned, drained and rinsed ..............................................................1⁄2 cup

Lentils (any color), cooked ...............................1⁄2 cup

Peas (black-eyed and split), cooked or canned, drained and rinsed .............................

1⁄2 cup

Refried beans, canned................................. 1⁄2 cup

Note: Beans, lentils, and peas are also found on the Protein list, page C-6.

*Note: Restaurant-style French fries are on the Fast Foods list, page C-11.

Fruits One fruit choice has 15 grams of carbohydrate and 60 calories.

Icon Key

= Good source of fiber ! = Extra fat

= High in sodium

Food Serving Size Fruits

The weights listed include skin, core, seeds, and rind.

Apple, unpeeled ................................................. 1 small apple (4 oz)

Apples, dried ...................................................... 4 rings

Applesauce, unsweetened .................................. 1⁄2 cup

Apricots

canned ........................................................... 1⁄2 cup

dried ............................................................... 8 apricot halves

fresh ............................................................... 4 apricots (51⁄2 oz total)

Banana ............................................................... 1 extra-small banana, about 4 inches long (4 oz)

Blackberries ........................................................ 1 cup

Blueberries ......................................................... 3⁄4 cup

Cantaloupe ......................................................... 1 cup diced

Cherries

sweet, canned ................................................ 1⁄2 cup

sweet, fresh .................................................... 12 cherries (31⁄2 oz)

Dates .................................................................. 3 small (deglet noor) dates or 1 large (medjool) date

Food Serving Size Dried fruits (blueberries, cherries, cranberries,

mixed fruit, raisins) 2 Tbsp

Figs

dried ............................................................. 3 small figs

fresh ............................................................. 11⁄2 large or 2 medium figs (31⁄2 oz total)

Fruit cocktail ....................................................... 1⁄2 cup

Grapefruit

fresh ............................................................. 1⁄2 large grapefruit (5 1⁄2 oz)

sections, canned .......................................... 3⁄4 cup

Grapes ............................................................... 17 small grapes (3 oz total)

Guava ................................................................ 2 small guava (21⁄2 oz total)

Honeydew melon ............................................... 1 cup diced

Kiwi .................................................................... 1⁄2 cup sliced

Loquat ................................................................ 3⁄4 cup cubed

Mandarin oranges, canned ................................. 3⁄4 cup

Appendix C | U.S. Exchange Lists for Meal Planning C-3

Food Serving Size Mango ................................................................ 1⁄2 small mango (51⁄2 oz)

or 1⁄2 cup

Nectarine ............................................................ 1 medium nectarine (51⁄2 oz)

Orange ............................................................... 1 medium orange (61⁄2 oz)

Papaya ............................................................... 1⁄2 papaya (8 oz) or 1 cup cubed

Peaches

canned ......................................................... 1⁄2 cup

fresh ............................................................. 1 medium peach (6 oz)

Pears

canned ......................................................... 1⁄2 cup

fresh ............................................................. 1⁄2 large pear (4 oz)

Pineapple

canned ......................................................... 1⁄2 cup

fresh ............................................................. 3⁄4 cup

Plantain, extra-ripe (black), raw ........................... 1⁄4 plantain (21⁄4 oz)

Plums

canned ......................................................... 1⁄2 cup

Food Serving Size dried (prunes) 3 prunes

fresh ............................................................. 2 small plums (5 oz total)

Pomegranate seeds (arils) ................................... 1⁄2 cup

Raspberries ........................................................ 1 cup

Strawberries ....................................................... 11⁄4 cup whole berries

Tangerine ............................................................ 1 large tangerine (6 oz)

Watermelon ........................................................ 11⁄4 cup diced

Fruit Juice

Apple juice/cider ................................................. 1⁄2 cup

Fruit juice blends, 100% juice ............................. 1⁄3 cup

Grape juice ......................................................... 1⁄3 cup

Grapefruit juice ................................................... 1⁄2 cup

Orange juice ....................................................... 1⁄2 cup

Pineapple juice ................................................... 1⁄2 cup

Pomegranate juice .............................................. 1⁄2 cup

Prune juice ......................................................... 1⁄3 cup

Milk and Milk Substitutes One carbohydrate choice has 15 grams of carbohydrate and about 70 calories. One fat choice has 5 grams of fat and 45 calories.

Food Serving Size Choices per Serving Milk and Yogurts

Fat-Free (Skim) or Low-Fat (1%)

milk, buttermilk, acidophilus milk, lactose-free milk ............................................. 1 cup ................................................. 1 fat-free milk

evaporated milk .................................................................................................. 1⁄2 cup ...................................................... 1 fat-free milk

yogurt, plain or Greek; may be sweetened with an artificial sweetener ................ 2⁄3 cup (6 oz) ......................................... 1 fat-free milk

Chocolate milk .................................................................................................... 1 cup ................................................. 1 fat@free milk + 1 carbohydrate Reduced-Fat (2%)

milk, acidophilus milk, kefir, lactose-free milk ...................................................... 1 cup ................................................. 1 reduced-fat milk

yogurt, plain........................................................................................................ 2⁄3 cup (6 oz) ......................................... 1 reduced-fat milk

Whole .......................................................................................................................

milk, buttermilk, goat’s milk ................................................................................. 1 cup ................................................. 1 whole milk

evaporated milk .................................................................................................. 1⁄2 cup .................................................. 1 whole milk

yogurt, plain........................................................................................................ 1 cup (8 oz) ............................................. 1 whole milk

chocolate milk .................................................................................................... 1 cup ................................................. 1 whole milk + 1 carbohydrate

Other Milk Foods and Milk Substitutes Eggnog

fat-free .......................................................................................................... 1⁄3 cup ................................................ 1 carbohydrate

low-fat .......................................................................................................... 1⁄3 cup ................................................ 1 carbohydrate 1⁄2 fat

whole milk .................................................................................................... 1⁄3 cup ...................................................... 1 carbohydrate + 1 fat Rice drink

plain, fat-free ................................................................................................ 1 cup ................................................. 1 carbohydrate

flavored, low-fat ............................................................................................ 1 cup ................................................. 2 carbohydrates

Soy milk

light or low-fat, plain ..................................................................................... 1 cup ................................................. 1⁄2 carbohydrate + 1⁄2 fat regular, plain ................................................................................................. 1 cup ................................................. 1⁄2 carbohydrate + 1fat

Yogurt with fruit, low-fat ...................................................................................... 2⁄3 cup (6 oz) ....................................... 1 fat@free milk + 1 carbohydrate

Note: Unsweetened nut milks (such as almond milk and coconut milk) are on the Fats list, page C-8.

C-4 Appendix C | U.S. Exchange Lists for Meal Planning

Nonstarchy Vegetables One nonstarchy vegetable choice (1⁄2 cup cooked or 1 cup raw) has 5 grams of carbohydrate, 2 grams of protein, 0 grams of fat, and 25 calories.

Icon Key

= Good source of fiber ! = Extra fat

= High in sodium

Nonstarchy Vegetables

Amaranth leaves (Chinese spinach) Artichoke Artichoke hearts (no oil) Asparagus Baby corn Bamboo shoots Bean sprouts (alfalfa, mung, soybean) Beans (green, wax, Italian, yard-long beans) Beets Broccoli Broccoli slaw, packaged, no dressing

Brussels sprouts Cabbage (green, red, bok choy, Chinese)

Carrots Cauliflower Celery Chayote Coleslaw, packaged, no dressing Cucumber Daikon Eggplant Fennel Gourds (bitter, bottle, luffa, bitter melon) Green onions or scallions Greens (collard, dandelion, mustard, purslane, turnip)

Hearts of palm ✓ Jicama

Kale Kohlrabi Leeks Mixed vegetables (without starchy vegetables, legumes, or pasta) Mushrooms, all kinds, fresh Okra Onions Pea pods Peppers (all varieties) Radishes Rutabaga

Sauerkraut, drained and rinsed Spinach Squash, summer varieties (yellow, pattypan, crookneck, zucchini) Sugar snap peas Swiss chard Tomato Tomatoes, canned

Tomato sauce (unsweetened) Tomato/vegetable juice Turnips Water chestnuts

Note: Salad greens (like arugula, chicory, endive, escarole, lettuce, radicchio, romaine, and watercress) are on the Free Foods list, page C-9.

Sweets, Desserts, and Other Carbohydrates One carbohydrate choice has 15 grams of carbohydrate and about 70 calories. One fat choice has 5 grams of fat and 45 calories.

Icon Key

= Good source of fiber ! = Extra fat

= High in sodium

Food Serving Size Choices per Serving

Beverages, Soda, and Sports Drinks Cranberry juice cocktail ............................................................................................... 1⁄2 cup ............................................ 1 carbohydrate

Fruit drink or lemonade ................................................................................................ 1 cup (8 oz) ................................... 2 carbohydrates

Hot chocolate, regular ................................................................................................. 1 envelope (2 Tbsp or 3⁄4 oz) ........... added to 8 oz water

1 carbohydrate

Soft drink (soda), regular .............................................................................................. 1 can (12 oz).................................. 21⁄2 carbohydrates

Sports drink (fluid replacement type) ............................................................................ 1 cup (8 oz) ......................................... 1 carbohydrate

Brownies, Cake, Cookies, Gelatin, Pie, and Pudding Biscotti ............................................................................................................................ 1 oz ............................................... 1 carbohydrate + 1 fat

Brownie, small, unfrosted ................................................................................................ 11⁄4 -inch square, 7⁄8--inch high ........ (about 1 oz)

1 carbohydrate + 1 fat

Appendix C | U.S. Exchange Lists for Meal Planning C-5

Food Serving Size Choices per Serving Cake

angel food, unfrosted ............................................................................................. 1⁄12 of cake (about 2 oz) ................... 2 carbohydrates

frosted ................................................................................................................... 2-inch square (about 2 oz) ............. 2 carbohydrates + 1 fat unfrosted ............................................................................................................... 2-inch square (about 1 oz) ............. 1 carbohydrate + 1 fat

Cookies

100-calorie pack .................................................................................................... 1 oz ............................................... 1 carbohydrate + 1⁄2 fat chocolate chip cookies .......................................................................................... 2 cookies, 21⁄4 inches across .......... 1 carbohydrate + 2 fats gingersnaps ........................................................................................................... 3 small cookies, 11⁄2 inches across . 1 carbohydrate

large cookie ........................................................................................................... 1 cookie, 6 inches across .............. (about 3 oz)

4 carbohydrates + 3 fats

sandwich cookies with crème filling ....................................................................... 2 small cookies (about 2⁄3 oz) .......... 1 carbohydrate + 1 fat sugar-free cookies ................................................................................................. 1 large or 3 small cookies (3⁄4 to 1

oz) .............................................. 1 carbohydrate + 1 to 2 fats

vanilla wafer ........................................................................................................... 5 cookies ....................................... 1 carbohydrate + 1 fat Cupcake, frosted ......................................................................................................... 1 small cupcake (about 13⁄4 oz) ....... 2 carbohydrates + 1 to 11⁄2 fats Flan ............................................................................................................................. 1⁄2 cup............................................. 21⁄2 carbohydrates + 1 fat Fruit cobbler ................................................................................................................ 1⁄2 cup (31⁄2 oz) ................................. 3 carbohydrates + 1 fat Gelatin, regular ............................................................................................................ 1⁄2 cup............................................. 1 carbohydrate

Pie

commercially prepared fruit, 2 crusts ..................................................................... 1⁄6 of 8-inch pie .............................. 3 carbohydrates + 2 fats pumpkin or custard ............................................................................................... 1⁄8 of 8-inch pie .............................. 11⁄2 carbohydrates + 11⁄2 fats

Pudding

regular (made with reduced-fat milk). ..................................................................... 1⁄2 cup............................................. 2 carbohydrates

sugar-free or sugar- and fat-free (made with fat-free milk) ...................................... 1⁄2 cup............................................. 1 carbohydrate

Candy, Spreads, Sweets, Sweeteners, Syrups, and Toppings Blended sweeteners (mixtures of artificial sweeteners and sugar) ................................. 11⁄2 Tbsp ......................................... 1 carbohydrate

Candy

chocolate, dark or milk type ................................................................................... 1 oz ............................................... 1 carbohydrate + 2 fats chocolate “kisses” 5 pieces ........................................ 1 carbohydrate + 1 fat hard ....................................................................................................................... 3 pieces ........................................ 1 carbohydrate

Coffee creamer, nondairy type

powdered, flavored ................................................................................................ 4 tsp .............................................. 1⁄2 carbohydrate + 1⁄2 fat liquid, flavored ....................................................................................................... 2 Tbsp ........................................... 1 carbohydrate

Fruit snacks, chewy (pureed fruit concentrate) ............................................................. 1 roll ( 3⁄4 oz) .................................... 1 carbohydrate

Fruit spreads, 100% fruit .............................................................................................. 11⁄2 Tbsp ......................................... 1 carbohydrate

Honey .......................................................................................................................... 1 Tbsp ........................................... 1 carbohydrate

Jam or jelly, regular ...................................................................................................... 1 Tbsp ........................................... 1 carbohydrate

Sugar .......................................................................................................................... 1 Tbsp ........................................... 1 carbohydrate

Syrup

chocolate .............................................................................................................. 2 Tbsp ........................................... 2 carbohydrates

light (pancake-type) ............................................................................................... 2 Tbsp ........................................... 1 carbohydrate

regular (pancake-type) ........................................................................................... 1 Tbsp ........................................... 1 carbohydrate

Condiments and Sauces Barbecue sauce .......................................................................................................... 3 Tbsp ........................................... 1 carbohydrate

Cranberry sauce, jellied ................................................................................................ 1⁄4 cup............................................. 11⁄2 carbohydrates

Curry sauce ................................................................................................................. 1 oz ............................................... 1 carbohydrate + 1 fat

Gravy, canned or bottled ............................................................................................. 1⁄2 cup............................................. 1⁄2 carbohydrate + 1⁄2 fat

Hoisin sauce ................................................................................................................ 1 Tbsp ........................................... 1⁄2 carbohydrate

Marinade ..................................................................................................................... 1 Tbsp ........................................... 1⁄2 carbohydrate

Plum sauce ................................................................................................................. 1 Tbsp ........................................... 1⁄2 carbohydrate

Salad dressing, fat-free, cream-based ......................................................................... 3 Tbsp ........................................... 1 carbohydrate

Sweet-and-sour sauce ................................................................................................ 3 Tbsp ........................................... 1 carbohydrate

Doughnuts, Muffins, Pastries, and Sweet Breads Banana nut bread ........................................................................................................ 1-inch slice (2 oz) ........................... 2 carbohydrates + 1 fat Doughnut

cake, plain ............................................................................................................. 1 medium doughnut (11⁄2 oz) ........... 11⁄2 carbohydrates + 2 fats hole ....................................................................................................................... 2 holes (1 oz) ................................. 1 carbohydrate + 1 fat

C-6 Appendix C | U.S. Exchange Lists for Meal Planning

Food Serving Size Choices per Serving yeast-type, glazed ................................................................................................. 1 doughnut, 3 3⁄4 inches across (2 oz) 2 carbohydrates + 2 fats

Muffin

regular ................................................................................................................... 1 muffin (4 oz) ................................ 4 carbohydrates + 21⁄2 fats

lower-fat ................................................................................................................ 1 muffin (4 oz) ................................ 4 carbohydrates + 1⁄2 fat

Scone .............................................................................................................................. 1 scone (4 oz) ................................ 4 carbohydrates + 3 fats

Sweet roll or Danish ......................................................................................................... 1 pastry (21⁄2 oz) ............................ 21⁄2 carbohydrates + 2 fats

Frozen Bars, Frozen Dessert, Frozen Yogurt, and Ice Cream Frozen pops .................................................................................................................... 1.................................................... 1⁄2 carbohydrate

Fruit juice bars, frozen, 100% juice ................................................................................... 1 bar (3 oz) .................................... 1 carbohydrate

Ice cream

fat-free ......................................................................................................................... 1⁄2 cup............................................. 11⁄2 carbohydrates

light ............................................................................................................................. 1⁄2 cup............................................. 1 carbohydrate + 1 fat

no-sugar-added .......................................................................................................... 1⁄2 cup............................................. 1 carbohydrate + 1 fat

regular ......................................................................................................................... 1⁄2 cup............................................. 1 carbohydrate + 2 fats

Sherbet, sorbet ............................................................................................................... 1⁄2 cup............................................. 2 carbohydrates

Yogurt, frozen

fat-free ......................................................................................................................... 1⁄3 cup............................................. 1 carbohydrate

regular ......................................................................................................................... 1⁄2 cup............................................. 1 carbohydrate + 091 fat

Greek, low-fat or fat-free .............................................................................................. 1⁄2 cup............................................. 11⁄2 carbohydrates

Note: You can also check the Fats list and Free Foods list for other condiments.

Protein One lean protein choice has 0 grams of carbohydrate, 7 grams of protein, 2 grams of fat, and 45 calories.

Icon Key

= Good source of fiber ! = Extra fat

= High in sodium (based on the sodium content of a typical 3-oz serving of meat, unless 1 oz or 2 oz is the normal serving size)

Food Serving Size

Lean Protein Note: 1 oz is usually the serving size for meat, fish, poultry, or hard cheeses.

Beef: ground (90% or higher lean/10% ................... or lower fat); select or choice grades trimmed of fat: roast (chuck, round, rump, sirloin), steak (cubed, flank, porterhouse, T-bone), tenderloin

1 oz

Beef jerky ................................................................ 1⁄2 oz

Cheeses with 3 grams of fat or less per oz .............. 1 oz

Curd-style cheeses: cottage-type (all kinds); ricotta (fat-free or light)

1⁄4 cup (2 oz)

Egg substitutes, plain .............................................. 1⁄2 cup

Egg whites............................................................... 2

Fish .........................................................................

fresh or frozen, such as catfish, cod, ................... flounder, haddock, halibut, orange roughy, tilapia, trout ....................................................

1 oz

salmon, fresh or canned ...................................... 1 oz

sardines, canned ................................................. 2 small sardines

Food Serving Size tuna, fresh or canned in water or .........................

oil and drained 1 oz

smoked: herring or salmon (lox) ........................... 1 oz

Game: buffalo, ostrich, rabbit, venison ..................... 1 oz

Hot dog with 3 grams of fat or less per oz .............. (Note: May contain carbohydrate.)

1 hot dog (13⁄4 oz)

Lamb: chop, leg, or roast ........................................ 1 oz

Organ meats: heart, kidney, liver . ........................ (Note: May be high in cholesterol.)

1 oz

Oysters, fresh or frozen ............................................ 6 medium oysters

Pork, lean ................................................................

Canadian bacon .................................................. 1 oz

ham ..................................................................... 1 oz

rib or loin chop/roast, tenderloin .......................... 1 oz

Poultry, without skin: chicken; Cornish hen; domestic duck or goose (well drained of fat); turkey; lean ground turkey or chicken ................ 1 oz

Appendix C | U.S. Exchange Lists for Meal Planning C-7

Food Serving Size

Processed sandwich meats with 3 grams of fat or less per oz: chipped beef, thin-sliced deli meats, turkey ham, turkey pastrami ................... 1 oz

Sausage with 3 grams of fat or less per oz .............. 1 oz

Shellfish: clams, crab, imitation shellfish, lobster, scallops, shrimp................................................. 1 oz

Veal: cutlet (no breading), loin chop, roast ................ 1 oz

Medium-Fat Protein One medium-fat protein choice has 0 grams of carbohydrate, 7 grams of

protein, 5 grams of fat, and 75 calories. Note: 1 oz is usually the serving size for meat, fish, poultry, or hard cheeses.

Beef trimmed of visible fat: ground beef (85% or lower lean/15% or higher fat), corned beef, meatloaf, prime cuts of beef (rib roast), short ribs, tongue ....................................................... 1 oz

Cheeses with 4–7 grams of fat per oz: feta, mozzarella, pasteurized processed cheese spread, reduced-fat cheeses ............................. 1 oz

Cheese, ricotta (regular or part-skim) ....................... 1⁄4 cup (2 oz)

Egg ......................................................................... 1 egg

Fish: any fried .......................................................... 1 oz

Lamb: ground, rib roast ........................................... 1 oz

Pork: cutlet, ground, shoulder roast ......................... 1 oz

Poultry with skin: chicken, dove, pheasant, turkey, wild duck, or goose; fried chicken ...................... 1 oz

Sausage with 4–7 grams of fat per oz ...................... 1 oz

Food Serving Size

High-Fat Protein These foods are high in saturated fat, cholesterol, and calories and may raise blood cholesterol levels if eaten on a regular basis. Try to eat 3 or fewer choices from this group per week. Note: 1 oz is usually the serving size for meat, fish, poultry, or hard cheeses.

Bacon, pork............................................................. 2 slices (1 oz each before cooking)

Bacon, turkey .......................................................... 3 slices (1⁄2 oz each before cooking)

Cheese, regular: American, blue-veined, brie, cheddar, hard goat, Monterey jack, Parmesan, queso, and Swiss .............................................. 1 oz

! Hot dog: beef, pork, or combination ........................ 1 hot dog (10 hot dogs per 1 lb-sized package)

Hot dog: turkey or chicken ...................................... 1 hot dog (10 hot dogs per 1 lb-sized package)

Pork: sausage, spareribs ......................................... 1 oz

Processed sandwich meats with 8 grams of ............ fat or more per oz: bologna, hard salami, pastrami

1 oz

Sausage with 8 grams fat or more per oz: ............... bratwurst, chorizo, Italian, knockwurst, Polish, smoked, summer

1 oz

Protein Icon Key

= Good source of fiber ! = Extra fat

= High in sodium (based on the sodium content of a typical 3-oz serving of meat, unless 1 oz or 2 oz is the normal serving size)

Food Serving Size Choices per Serving

Plant-Based Protein Because carbohydrate and fat content varies among plant-based proteins, you should read the food labels. “Bacon” strips, soy-based ..................................................................................... 2 strips (1⁄2 oz) ............................. 1 lean protein

Baked beans, canned ........................................................................................... 1⁄3 cup ......................................... 1 starch + 1 lean protein

Beans (black, garbanzo, kidney, lima, navy, pinto, white), cooked or canned, drained and rinsed ................................................................................................. 1⁄2 cup .........................................

1 starch + 1 lean protein

“Beef” or “sausage” crumbles, meatless ................................................................ 1 oz ............................................ 1 lean protein “Chicken” nuggets, soy-based............................................................................... 2 nuggets (11⁄2 oz) ....................... 1⁄2 carbohydrate + 1 medium-fat protein

Edamame, shelled ................................................................................................. 1⁄2 cup ......................................... 1⁄2 carbohydrate + 1 lean protein Falafel (spiced chickpea and wheat patties) ........................................................... 3 patties (about 2 inches across) 1 carbohydrate + 1 high-fat protein Hot dog, meatless, soy-based ............................................................................... 1 hot dog (11⁄2 oz) ....................... 1 lean protein

Hummus ............................................................................................................... 1⁄3 cup ......................................... 1 carbohydrate + 1 medium-fat protein

Lentils, any color, cooked or canned, drained and rinsed ....................................... 1⁄2 cup ......................................... 1 starch + 1 lean protein Meatless burger, soy-based ................................................................................... 3 oz ............................................ 1⁄2 carbohydrate + 2 lean proteins

Meatless burger, vegetable and starch-based ....................................................... 1 patty (about 21⁄2 oz ) ................. 1⁄2 carbohydrate + 1 lean protein Meatless deli slices ................................................................................................ 1 oz ............................................ 1 lean protein Mycoprotein (“chicken” tenders or crumbles), meatless ......................................... 2 oz ............................................ 1⁄2 carbohydrate + 1 lean protein Nut spreads: almond butter, cashew butter, peanut butter, soy nut butter ............. 1 Tbsp ........................................ 1 high-fat protein

Peas (black-eyed and split peas), cooked or canned, drained and rinsed .............. 1⁄2 cup ......................................... 1 starch + 1 lean protein

Refried beans, canned..................................................................................... 1⁄2 cup ......................................... 1 starch + 1 lean protein

“Sausage” breakfast-type patties, meatless ........................................................... 1(11⁄2 oz)...................................... 1 medium-fat protein Soy nuts, unsalted ................................................................................................. 3⁄4 oz ........................................... 1⁄2 carbohydrate + 1 medium-fat protein Tempeh, plain, unflavored ...................................................................................... 1⁄4 cup (11⁄2 oz) ............................ 1 medium-fat protein Tofu ....................................................................................................................... 1⁄2 cup (4 oz) ................................ 1 medium-fat protein Tofu, light ............................................................................................................... 1⁄2 cup (4 oz) ................................ 1 lean protein

C-8 Appendix C | U.S. Exchange Lists for Meal Planning

Fats One fat choice has 5 grams of fat and 45 calories.

Food Serving Size Unsaturated Fats—Monounsaturated Fats

Almond milk (unsweetened) ...................................... 1 cup

Avocado, medium .................................................... 2 Tbsp (1 oz)

Nut butters (trans fat-free): almond butter, ................ cashew butter, peanut butter (smooth or crunchy)

11⁄2 tsp

Nuts

almonds ............................................................. 6 nuts

Brazil .................................................................. 2 nuts

cashews ............................................................. 6 nuts

filberts (hazelnuts) ............................................... 5 nuts

macadamia ......................................................... 3 nuts

mixed (50% peanuts) .......................................... 6 nuts

peanuts .............................................................. 10 nuts

pecans ............................................................... 4 halves

pistachios ........................................................... 16 nuts

Oil: canola, olive, peanut ........................................... 1 tsp

Olives

black (ripe) .......................................................... 8

green, stuffed ..................................................... 10 large

Spread, plant stanol ester-type

light .................................................................... 1 Tbsp

regular ................................................................ 2 tsp

Unsaturated Fats—Polyunsaturated Fats Margarine

lower-fat spread (30–50% vegetable ................... oil, trans fat-free) .............................................

1 Tbsp

stick, tub (trans fat-free), or squeeze .................. (trans fat-free) ..................................................

1 tsp

Mayonnaise

reduced-fat ......................................................... 1 Tbsp

regular ................................................................ 1 tsp

Mayonnaise-style salad dressing

reduced-fat ......................................................... 1 Tbsp

regular ................................................................ 2 tsp

Nuts .........................................................................

pignolia (pine nuts) 1 Tbsp

walnuts, English .................................................. 4 halves

Oil: corn, cottonseed, flaxseed, grapeseed, .............. safflower, soybean, sunflower

1 tsp

Food Serving Size Salad dressing

reduced-fat (Note: May contain carbohydrate.) ..... 2 Tbsp

regular ................................................................ 1 Tbsp

Seeds

flaxseed, ground ................................................. 11⁄2 Tbsp

pumpkin, sesame, sunflower .............................. 1 Tbsp

Tahini or sesame paste ............................................. 2 tsp

Saturated Fats Bacon, cooked, regular or turkey .............................. 1 slice

Butter

reduced-fat ......................................................... 1 Tbsp

stick ................................................................... 1 tsp

whipped ............................................................. 2 tsp

Butter blends made with oil

reduced-fat or light ............................................. 1 Tbsp

regular ................................................................ 11⁄2 tsp

Chitterlings, boiled .................................................... 2 Tbsp ( 1⁄2 oz)

Coconut, sweetened, shredded ................................ 2 Tbsp

Coconut milk, canned, thick

light .................................................................... 1⁄3 cup

regular ................................................................ 11⁄2 Tbsp

Coconut milk beverage (thin), unsweetened .............. 1 cup

Cream

half-and-half ....................................................... 2 Tbsp

heavy .................................................................. 1 Tbsp

light .................................................................... 11⁄2 Tbsp

whipped ............................................................. 2 Tbsp

Cream cheese

reduced-fat ......................................................... 11⁄2 Tbsp ( 3⁄4 oz)

regular ................................................................ 1 Tbsp ( 1⁄2 oz)

Lard .......................................................................... 1 tsp

Oil: coconut, palm, palm kernel ................................ 1 tsp

Salt pork ................................................................... 1⁄4 oz

Shortening, solid ....................................................... 1 tsp

Sour cream

reduced-fat or light ............................................. 3 Tbsp

regular ................................................................ 2 Tbsp

Appendix C | U.S. Exchange Lists for Meal Planning C-9

Free Foods A “free” food is any food or drink choice that has less than 20 calories and 5 grams or less of carbohydrate per serving.

Icon Key

= Good source of fiber

! = Extra fat

= High in sodium

Food Serving Size Low-Carbohydrate Foods

Candy, hard (regular or sugar-free)............................ 1 piece

Fruits

Cranberries or rhubarb, sweetened with sugar substitute ......................................................... 1⁄2 cup

Gelatin dessert, sugar-free, any flavor .......................

Gum, sugar-free .......................................................

Jam or jelly, light or no-sugar-added ......................... 2 tsp

Salad greens (such as arugula, chicory, endive, escarole, leaf or iceberg lettuce, purslane, romaine, radicchio, spinach, watercress)

Sugar substitutes (artificial sweeteners) .....................

Syrup, sugar-free ...................................................... 2 Tbsp

Vegetables: any raw nonstarchy vegetables ............ (such as broccoli, cabbage, carrots, cucumber, tomato)

1⁄2 cup

Vegetables: any cooked nonstarchy vegetables ...... (such as carrots, cauliflower, green beans)

1⁄4 cup

Reduced-Fat or Fat-Free Foods Cream cheese, fat-free ............................................. 1 Tbsp (1⁄2 oz)

Coffee creamers, nondairy

liquid, flavored .................................................... 11⁄2 tsp

liquid, sugar-free, flavored ................................... 4 tsp

powdered, flavored ............................................. 1 tsp

powdered, sugar-free, flavored ........................... 2 tsp

Margarine spread

fat-free ................................................................ 1 Tbsp

reduced-fat ......................................................... 1 tsp

Mayonnaise ..............................................................

fat-free ................................................................ 1 Tbsp

reduced-fat ......................................................... 1 tsp

Mayonnaise-style salad dressing

fat-free ................................................................ 1 Tbsp

reduced-fat ......................................................... 2 tsp

Food Serving Size Salad dressing

fat-free ................................................................ 1 Tbsp

fat-free, Italian ..................................................... 2 Tbsp

Sour cream, fat-free or reduced-fat........................... 1 Tbsp

Whipped topping

light or fat-free .................................................... 2 Tbsp

regular ................................................................ 1 Tbsp

Condiments Barbecue sauce ....................................................... 2 tsp

Catsup (ketchup) ...................................................... 1 Tbsp

Chili sauce, sweet, tomato-type ................................ 2 tsp

Horseradish ..............................................................

Hot pepper sauce .....................................................

Lemon juice ..............................................................

Miso ......................................................................... 11⁄2 tsp

Mustard ....................................................................

honey ................................................................. 1 Tbsp

brown, Dijon, horseradish-flavored, wasabi-flavored, or yellow

Parmesan cheese, grated ......................................... 1 Tbsp

Pickle relish (dill or sweet) ......................................... 1 Tbsp

Pickles ......................................................................

dill....................................................................... 11⁄2 medium pickles

sweet, bread and butter...................................... 2 slices

sweet, gherkin .................................................... 3⁄4 oz

Pimento ....................................................................

Salsa ........................................................................ 1⁄4 cup

Soy sauce, light or regular ........................................ 1 Tbsp

Sweet-and-sour sauce ............................................. 2 tsp

Taco sauce ............................................................... 1 Tbsp

Vinegar .....................................................................

Worcestershire sauce ...............................................

Yogurt, any type ....................................................... 2 Tbsp

Drinks/Mixes

Bouillon, broth, consommé Bouillon or broth, low sodium Carbonated or mineral water Club soda Cocoa powder, unsweetened (1 Tbsp) Coffee, unsweetened or with sugar substitute Diet soft drinks, sugar-free Drink mixes (powder or liquid drops), sugar-free Tea, unsweetened or with sugar substitute Tonic water, sugar-free

Water Water, flavored, sugar-free

Seasonings

Flavoring extracts (e.g., vanilla, almond, or peppermint) Garlic, fresh or powder Herbs, fresh or dried Kelp Nonstick cooking spray Spices Wine, used in cooking

Free Foods

C-10 Appendix C | U.S. Exchange Lists for Meal Planning

Combination Foods One carbohydrate choice has 15 grams of carbohydrate and about 70 calories.

Icon Key

= Good source of fiber

! = Extra fat

= High in sodium

Food Serving Size Choices per Serving Entrees Casserole-type entrees (tuna noodle, lasagna, ..............................

spaghetti with meatballs, chili with beans, macaroni and cheese)

1 cup (8 oz) ................................... 2 carbohydrates + 2 medium-fat proteins

Stews (beef/other meats and vegetables) ..................................... 1 cup (8 oz) ................................... 1 carbohydrate + 1 medium-fat protein + 093 fats

Frozen Meals/Entrees Burrito (beef and bean) ................................................................. 1 burrito (5 oz) ............................... 3 carbohydrates + 1 lean protein + 2 fats

Dinner-type healthy meal (includes dessert and is usually ............. less than 400 calories)

about 9–12 oz ............................... 293 carbohydrates + 192 lean proteins + 1 fat

“Healthy”-type entree (usually less than 300 calories) .................... about 7–10 oz ............................... 2 carbohydrates + 2 lean proteins Pizza

cheese/vegetarian, thin crust ........................................................ 1⁄4 of a 12-inch pizza (41⁄2–5 oz)....... 2 carbohydrates + 2 medium-fat proteins

meat topping, thin crust ................................................................ 1⁄4 of a 12-inch pizza (5 oz) ............. 2 carbohydrates + 2 medium-fat proteins + 11⁄2 fats

cheese/vegetarian or meat topping, rising crust ............................ 1⁄6 of 12-inch pizza (4 oz) ................ 21⁄2 carbohydrates + 2 medium-fat proteins

Pocket sandwich .......................................................................... 1 sandwich (41⁄2 oz) ....................... 3 carbohydrates + 1 lean protein + 1 to 2 fats

Pot pie .......................................................................................... 1 pot pie (7 oz) .............................. 3 carbohydrates + 1 medium-fat protein + 3 fats

Salads (Deli-Style) Coleslaw ....................................................................................... 1⁄2 cup............................................. 1 carbohydrate + 11⁄2 fats Macaroni/pasta salad ................................................................... 1⁄2 cup............................................. 2 carbohydrates + 3 fats

Potato salad ................................................................................. 1⁄2 cup............................................. 11⁄2 –2 carbohydrates + 1–2 fats

Tuna salad or chicken salad .......................................................... 1⁄2 cup (31⁄2 oz) ............................... 1⁄2 carbohydrate + 2 lean proteins + 1 fat

Soups

Bean, lentil, or split pea soup ........................................................ 1 cup (8 oz) ................................... 11⁄2 carbohydrates + 1 lean protein

Chowder (made with milk) ............................................................ 1 cup (8 oz) ................................... 1 carbohydrate + 1 lean protein + 11⁄2 fats

Cream soup (made with water) ..................................................... 1 cup (8 oz) ................................... 1 carbohydrate + 1 fat

Miso soup .................................................................................... 1 cup (8 oz) ................................... 1⁄2 carbohydrate + 1 lean protein

Ramen noodle soup ..................................................................... 1 cup (8 oz) ................................... 2 carbohydrates + 2 fats

Rice soup/porridge (congee) ......................................................... 1 cup (8 oz) ................................... 1 carbohydrate

Tomato soup (made with water), borscht ...................................... 1 cup (8 oz) ................................... 1 carbohydrate

Vegetable beef, chicken noodle, or other broth-type soup ............ (including “healthy”-type soups, such as those lower in sodium and/or fat)

1 cup (8 oz) ................................... 1 carbohydrate + 1 lean protein

Appendix C | U.S. Exchange Lists for Meal Planning C-11

Food Serving Size Choices per Serving Main Dishes/Entrees

Chicken

breast, breaded and fried* .................................................... 1 (about 7 oz) ................................. 1 carbohydrate + 6 medium-fat proteins

breast, meat only** ............................................................... 1..................................................... 4 lean proteins

drumstick, breaded and fried* .............................................. 1 (about 21⁄2 oz)............................... 1�2 carbohydrate + 2 medium-fat proteins

drumstick, meat only** ......................................................... 1..................................................... 1 lean protein + 1⁄2 fat

nuggets or tenders ............................................................... 6 (about 31⁄2 oz)............................... 1 carbohydrate + 2 medium-fat proteins + 1 fat

thigh, breaded and fried* ...................................................... 1 (about 5 oz) ................................. 1 carbohydrate + 3 medium-fat proteins + 2 fats

thigh, meat only** ................................................................. 1..................................................... 2 lean proteins + 1⁄2 fat

wing, breaded and fried* ...................................................... 1 wing (about 2 oz) ......................... 1⁄2 carbohydrate + 2 medium-fat proteins

wing, meat only** ................................................................. 1 wing ............................................ 1 lean protein

Main dish salad (grilled chicken type, no dressing or croutons) .. 1 salad (about 11⁄2 oz) ..................... 1 carbohydrate + 4 lean proteins

Pizza

cheese, pepperoni, or sausage, regular or thick crust........... 1⁄8 of a 14-inch pizza (about 4 oz) .... 21⁄2 carbohydrates + 1 high-fat protein + 1 fat

cheese, pepperoni, or sausage, thin crust ............................ 1⁄8 of a 14-inch pizza (about 23⁄4 oz)...... 11⁄2 carbohydrates + 1 high-fat protein + 1 fat

cheese, meat, and vegetable, regular crust .......................... 1⁄8 of a 14-inch pizza (about 5 oz) .... 21⁄2 carbohydrates + 2 high-fat proteins

Asian Beef/chicken/shrimp with vegetables in sauce ........................... 1 cup (about 6 oz) .......................... 1 carbohydrate + 2 lean proteins + 1 fat

Egg roll, meat ............................................................................ 1 egg roll (about 3 oz) ..................... 11⁄2 carbohydrates + 1 lean protein + 11⁄2 fats

Fried rice, meatless .................................................................... 1 cup .............................................. 21⁄2 carbohydrates + 2 fats

Fortune cookie ........................................................................... 1 cookie ......................................... 1⁄2 carbohydrate

Hot-and-sour soup .................................................................... 1 cup .............................................. 1⁄2 carbohydrate + 1⁄2 fat

Meat with sweet sauce............................................................... 1 cup (about 6 oz) .......................... 31⁄2 carbohydrates + 3 medium-fat proteins + 3 fats

Noodles and vegetables in sauce (chow mein, lo mein) .............. 1 cup .............................................. 2 carbohydrates + 2 fats

Mexican

Burrito with beans and cheese ................................................... 1 small burrito (about 6 oz) ............. 31⁄2 carbohydrates + 1 medium-fat protein + 1 fat

Nachos with cheese ................................................................... 1 small order (about 8 nachos) ....... 21⁄2 carbohydrates + 1 high-fat protein + 2 fats

Quesadilla, cheese only .............................................................. 1 small order (about 5 oz) ............... 21⁄2 carbohydrates + 3 high-fat proteins

Taco, crisp, with meat and cheese ............................................. 1 small taco (about 3 oz) ................. 1 carbohydrate + 1 medium-fat protein + 1⁄2 fat

Taco salad with chicken and tortilla bowl ................................... 1 salad (1 lb, including tortilla bowl) . 31⁄2 carbohydrates + 4 medium-fat proteins + 3 fats

Tostada with beans and cheese ................................................. 1 small tostada (about 5 oz) ............ 2 carbohydrates + 1 high-fat protein

Sandwiches Breakfast Sandwiches

Breakfast burrito with sausage, egg, cheese ........................ 1 burrito (about 4 oz) ...................... 11⁄2 carbohydrates + 2 high-fat proteins

Egg, cheese, meat on an English muffin .............................. 1 sandwich ..................................... 2 carbohydrates + 3 medium-fat proteins + 1⁄2 fat

*Definition and weight refer to food with bone, skin, and breading. **Definition refers to above food without bone, skin, and breading.

Fast Foods One carbohydrate choice has 15 grams of carbohydrate and about 70 calories.

Icon Key

= Good source of fiber

! = Extra fat = High in sodium

C-12 Appendix C | U.S. Exchange Lists for Meal Planning

Food Serving Size Choices per Serving

Egg, cheese, meat on a biscuit .................................................. 1 sandwich ..................................... 2 carbohydrates + 3 medium-fat proteins + 2 fats

Sausage biscuit sandwich .......................................................... 1 sandwich ..................................... 2 carbohydrates + 1 high-fat protein + 4 fats

Chicken Sandwiches

grilled with bun, lettuce, tomatoes, spread ........................... 1 sandwich (about 71⁄2 oz) ............... 3 carbohydrates + 4 lean proteins

crispy, with bun, lettuce, tomatoes, spread .......................... 1 sandwich (about 6 oz) .................. 3 carbohydrates + 2 lean proteins + 31⁄2 fats

Fish sandwich with tartar sauce and cheese .............................. 1 sandwich (5 oz) ........................... 21⁄2 carbohydrates + 2 medium-fat proteins + 11⁄2 fats

Hamburger

regular with bun and condiments (catsup, mustard, onion, pickle) ............................................................................... 1 burger (about 31⁄2 oz) ................... 2 carbohydrates + 1 medium-fat protein + 1 fat

4 oz meat with cheese, bun, and condiments (catsup, mustard, onion, pickle) ...................................... 1 burger (about 81⁄2 oz) ................... 3 carbohydrates + 4 medium-fat proteins + 21⁄2 fats

Hot dog with bun, plain .............................................................. 1 hot dog (about 31⁄2 oz).................. 11⁄2 carbohydrates + 1 high-fat protein + 2 fats

Submarine sandwich (no cheese or sauce)

less than 6 grams fat ............................................................ 1 6-inch sub ................................... 3 carbohydrates + 2 lean proteins

regular .................................................................................. 1 6-inch sub ................................... 3 carbohydrates + 2 lean proteins + 1 fat

Wrap, grilled chicken, vegetables, cheese, and spread ......... 1 small wrap (about 4–5 oz) ............ 2 carbohydrates + 2 lean proteins + 11⁄2 fats

Sides/Appetizers ! French fries ................................................................................ 1 small order (about 31⁄2 oz) ............ 21⁄2 carbohydrates + 2 fats

1 medium order (about 5 oz) ........... 31⁄2 carbohydrates + 3 fats

1 large order (about 6 oz) ................ 41⁄2 carbohydrates + 4 fats

Hashbrowns ............................................................................... 1 cup/medium order (about 5 oz) .... 3 carbohydrates + 6 fats

Onion rings ................................................................................ 1 serving (8–9 rings, about 4 oz) ..... 31⁄2 carbohydrates + 4 fats

Salad, side (no dressing, croutons, or cheese) ........................... 1 small salad .................................. 1 nonstarchy vegetable

Beverages and Desserts Coffee, latte (fat-free milk) .......................................................... 1 small order (about 12 oz) ............. 1 fat-free milk

Coffee, mocha (fat-free milk, no whipped cream) ....................... 1 small order (about 12 oz) ............. 1 fat-free milk + 1 carbohydrate

Milkshake, any flavor .................................................................. 1 small shake (about 12 oz) ............ 51⁄2 carbohydrates + 3 fats

1 medium shake (about 16 oz) ........ 7 carbohydrates + 4 fats

1 large shake (about 22 oz) ............. 10 carbohydrates + 5 fats

Soft-serve ice cream cone ......................................................... 1 small ............................................ 2 carbohydrates + 1⁄2 fat

Alcohol One alcohol equivalent or choice (1⁄2 oz absolute alcohol) has about 100 calories. One carbohydrate choice has 15 grams of carbohydrate and about 70 calories.

Alcoholic Beverage Serving Size Choices per Serving Beer

light (less than 4.5% abv) ............................................................................... 12 fl oz .................................. 1 alcohol equivalent + 1⁄2 carbohydrate

regular (about 5% abv) ................................................................................... 12 fl oz .................................. 1 alcohol equivalent + 1 carbohydrate

dark (more than 5.7% abv) ............................................................................ 12 fl oz .................................. 1 alcohol equivalent + 1 to 11⁄2 carbohydrates

Distilled spirits: (80 or 86 proof): vodka, rum, gin, whiskey, tequila ....................... 11⁄2 fl oz .................................. 1 alcohol equivalent

Liqueur, coffee (53 proof) ..................................................................................... 1 fl oz .................................... 1 alcohol equivalent + 1 carbohydrate

Sake .................................................................................................................... 1 fl oz .................................... 1⁄2 alcohol equivalent

Wine

champagne/sparkling .................................................................................... 5 fl oz .................................... 1 alcohol equivalent

dessert (sherry) .............................................................................................. 3½ fl oz ................................ 1 alcohol equivalent + 1 carbohydrate

dry, red or white (10% abv) ............................................................................ 5 fl oz .................................... 1 alcohol equivalent

Note: The abbreviation “% abv” refers to the percentage of alcohol by volume.

Appendix D | Organizations and Resources D-1

Academic Journals International Journal of Sport Nutrition and Exercise Metabolism www.humankinetics.com/IJSNEM

Journal of Nutrition www.jn.nutrition.org

Nutrition Research www.journals.elsevierhealth.com/periodicals/NTR

Nutrition www.nutritionjrnl.com

Nutrition Reviews http://onlinelibrary.wiley.com/journal/10.1111/ %28ISSN%291753-4887

Obesity http://onlinelibrary.wiley.com/journal/10.1111/ %28ISSN%291753-4887

International Journal of Obesity www.nature.com/ijo

Journal of the American Medical Association http://jama.ama-assn.org

New England Journal of Medicine www.nejm.org

American Journal of Clinical Nutrition www.ajcn.org

Journal of the Academy of Nutrition and Dietetics www.adajournal.org

Aging Administration on Aging www.aoa.gov

American Association of Retired Persons (AARP) www.aarp.org

Health and Age Sponsored by the Novartis Foundation for Gerontology and the Web-Based Health Education Foundation www.healthandage.com

National Council on Aging www.ncoa.org

International Osteoporosis Foundation www.iofbonehealth.org

National Institute on Aging www.nia.nih.gov

NIH Osteoporosis and Related Bone Diseases National Resource Center www.niams.nih.gov

American Geriatrics Society www.americangeriatrics.org

National Osteoporosis Foundation www.nof.org

Alcohol and Drug Abuse National Institute on Drug Abuse www.nida.nih.gov

National Institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gov

Alcoholics Anonymous www.alcoholics-anonymous.org

Narcotics Anonymous www.na.org

National Council on Alcoholism and Drug Dependence www.ncadd.org

National Clearinghouse for Alcohol and Drug Information http://ncadi.samhsa.gov

Canadian Government Health Canada www.hc-sc.gc.ca

Canadian Council of Food and Nutrition www.nin.ca

Agricultural and Agri-Food Canada www.arg.gc.ca

Canadian Food Inspection Agency www.inspection.gc.ca/english/toce.shtml

Canadian Institute for Health Information www.cihi.ca

Canadian Public Health Association www.cpha.ca

Appendix D Organizations and Resources

D-2 Appendix D | Organizations and Resources

Canadian Nutrition and Professional Organizations Dietitians of Canada, Canadian Dietetic Association www.dietitians.ca

Canadian Diabetes Association www.diabetes.ca

National Eating Disorder Information Centre www.nedic.ca

Canadian Paediatric Society www.cps.ca

Disordered Eating/Eating Disorders American Psychiatric Association www.psych.org

Harvard Eating Disorders Center www.mcleanhospital.org/programs/klarman-eating- disorders-center

National Institute of Mental Health www.nimh.nih.gov

National Association of Anorexia Nervosa and Associated Disorders (ANAD) www.anad.org

National Eating Disorders Association www.nationaleatingdisorders.org

Eating Disorder Referral and Information Center www.edreferral.com

Overeaters Anonymous www.oa.org

Weight Management http://wmdpg.org

Exercise, Physical Activity, and Sports American College of Sports Medicine (ACSM) www.acsm.org

American Physical Therapy Association (APTA) www.apta.org

Gatorade Sports Science Institute (GSSI) www.gssiweb.com

National Coalition for Promoting Physical Activity (NCPPA) www.ncppa.org

Sports, Cardiovascular, and Wellness Nutrition (SCAN) www.scandpg.org

President’s Council on Physical Fitness and Sports www.fitness.gov

American Council on Exercise www.acefitness.org

IDEA Health & Fitness Association www.ideafit.com

Food Safety Food Marketing Institute www.fmi.org

Agency for Toxic Substances and Disease Registry (ATSDR) www.atsdr.cdc.gov

Food Allergy and Anaphylaxis Network www.foodallergy.org

Foodsafety.gov www.foodsafety.gov

USDA Food Safety and Inspection Service www.fsis.usda.gov

Consumer Reports www.consumerreports.org

Center for Science in the Public Interest: Food Safety www.cspinet.org/foodsafety/index.html

Center for Food Safety and Applied Nutrition www.fda.gov/Food/FoodSafety

Food Safety Project www.extension.iastate.edu/foodsafety

Organic Consumers Association www.organicconsumers.org

Infancy and Childhood Administration for Children and Families www.acf.hhs.gov

American Academy of Pediatrics www.aap.org

Kidshealth: The Nemours Foundation www.kidshealth.org

National Center for Education in Maternal and Child Health www.ncemch.org

Birth Defects Research for Children, Inc. www.birthdefects.org

Appendix D | Organizations and Resources D-3

USDA/ARS Children’s Nutrition Research Center at Baylor College of Medicine www.kidsnutrition.org

Centers for Disease Control and Prevention—Healthy Youth www.cdc.gov/healthyyouth

International Agencies UNICEF www.unicef.org

World Health Organization www.who.int/en

Stockholm Convention on Persistent Organic Pollutants www.pops.int

Food and Agricultural Organization of the United Nations www.fao.org

International Food Information Council www.ific.org

Pregnancy and Lactation San Diego County Breastfeeding Coalition www.breastfeeding.org

National Alliance for Breastfeeding Advocacy www.naba-breastfeeding.org

American College of Obstetricians and Gynecologists www.acog.org

La Leche League www.lalecheleague.org

National Organization on Fetal Alcohol Syndrome www.nofas.org

March of Dimes Birth Defects Foundation http://modimes.org

Professional Nutrition Organizations Academy of Nutrition and Dietetics (AND) www.eatright.org

American Cancer Society www.cancer.org

American Dental Association www.ada.org

American Heart Association www.americanheart.org

American Medical Association www.ama-assn.org

Center for Science in the Public Interest www.cspinet.org

American Society for Nutrition (ASN) www.nutrition.org

Dietitians in Integrative and Functional Medicine www.complementarynutrition.org

Institute for Functional Medicine www.functionalmedicine.org

North American Association for the Study of Obesity (NAASO) www.naaso.org

Society for Nutrition Education www.sne.org

American College of Nutrition www.americancollegeofnutrition.org

American Obesity Association www.obesity.org

American Council on Science and Health www.acsh.org

American Diabetes Association www.diabetes.org

Institute of Food Technologists www.ift.org

ILSI Human Nutrition Institute www.ilsi.org

Trade Organizations American Meat Institute www.meatami.com

National Dairy Council www.nationaldairycouncil.org

United Fresh Fruit and Vegetable Association www.uffva.org

U.S.A. Rice Federation www.usarice.com

U.S. Government Agricultural Research Service www.ars.usda.gov

USDA National Organic Program Agricultural Marketing Service www.ams.usda.gov

D-4 Appendix D | Organizations and Resources

U.S. Department of Health and Human Services www.hhs.gov

Food and Drug Administration (FDA) www.fda.gov

Environmental Protection Agency www.epa.gov

Federal Trade Commission www.ftc.gov

Office of Dietary Supplements National Institutes of Health http://dietary-supplements.info.nih.gov

Nutrient Data Laboratory Beltsville Human Nutrition Research Center, Agricultural Research Service www.ars.usda.gov/nutrientdata

National Digestive Diseases Information Clearinghouse http://digestive.niddk.nih.gov

National Cancer Institute www.cancer.gov

National Eye Institute www.nei.nih.gov

National Heart, Lung, and Blood Institute www.nhlbi.nih.gov/index.htm

National Institute of Diabetes and Digestive and Kidney Diseases www.niddk.nih.gov

National Center for Complementary and Alternative Medicine http://nccam.nih.gov

U.S. Department of Agriculture (USDA) www.usda.gov

Centers for Disease Control and Prevention (CDC) www.cdc.gov

National Institutes of Health (NIH) www.nih.gov

Food and Nutrition Information Center Agricultural Research Service, USDA www.nal.usda.gov/fnic

National Institute of Allergy and Infectious Diseases www.niaid.nih.gov

Weight and Health Management North American Association for the Study of Obesity (NAASO) www.obesityresearch.org

Vegetarian Resource Group www.vrg.org

American Obesity Association www.obesity.org

Anemia Lifeline www.anemia.com

The Arc www.thearc.org

Bottled Water Web www.bottledwaterweb.com

Food and Nutrition Institute of Medicine www.iom.edu/Global/Topics/Food-Nutrition.aspx

Calorie Control Council www.caloriecontrol.org

TOPS (Take Off Pounds Sensibly) www.tops.org

Shape Up America! www.shapeup.org

World Hunger Center on Hunger, Poverty, and Nutrition Policy http://nutrition.tufts.edu

Freedom from Hunger www.freefromhunger.org

Oxfam International www.oxfam.org

WorldWatch Institute www.worldwatch.org

The Hunger Project www.thp.org

U.S. Agency for International Development www.usaid.gov

Feeding America www.feedingamerica.org

Food First www.foodfirst.org

Glossary G-1

1,25-dihydroxycholecalciferol (calcitriol) Active form of vita- min D.

5-methyltetrahydrofolate (5-methyl THF) Most active form of folate.

A absorption Process of moving nutrients from the GI tract into the circulatory system.

absorptive state Period after you eat when the stomach and small intestine are full and anabolic reactions exceed catabolic reactions.

Acceptable Macronutrient Distribution Ranges (AMDRs) Healthy range of intakes for the energy-containing nutrients— carbohydrates, proteins, and fats—expressed as a percentage of total daily energy. The AMDRs for adults are 45–65 percent car- bohydrates, 10–35 percent protein, and 20–35 percent fat.

acceptable tolerance levels Maximum amount of pesticide resi- due that is allowed in or on foods.

acetaldehyde dehydrogenase (ALDH) Alcohol-metabolizing enzyme found in the liver that converts acetaldehyde to acetate.

acetaldehyde One of the first compounds produced in the metabolism of ethanol. Eventually, acetaldehyde is converted to carbon dioxide and water and excreted.

acetyl CoA Two-carbon compound formed when pantothenic acid combines with acetate.

acid–base balance Mechanisms used to maintain body fluids close to a neutral pH so the body can function properly.

acidosis Condition in which the blood pH is too low, generally due to excessive hydrogen ions.

active transport Movement of substances across a cell mem- brane against their concentration gradient with the help of a car- rier protein and energy expenditure.

acute dehydration Dehydration that sets in after a short period of time.

acute Characterized by a sudden onset and rapid progression of symptoms.

added sugars Sugars added to foods during processing and/ or packaging.

adenosine diphosphate (ADP) Nucleotide composed of adenine, ribose, and two phosphate molecules; formed when one phosphate molecule is removed from ATP.

adenosine triphosphate (ATP) High-energy molecule com- posed of adenine, ribose, and three phosphate molecules; used by cells to fuel all biological processes.

Adequate Intake (AI) Approximate daily amount of a nutrient that is sufficient to meet the needs of similar individuals within a popu- lation group. The Food and Nutrition Board uses AIs for nutrients that do not have enough scientific evidence to calculate an RDA.

adipocytes Cells in adipose tissue that store fat; also known as fat cells.

adiponectin Hormone produced in the adipocytes that controls the body’s response to insulin and may be involved in reducing the risk of obesity and type 2 diabetes.

adolescence Developmental transition between childhood and early adulthood (approximately ages 9–19).

aerobic Reaction that requires oxygen.

age-related macular degeneration (AMD) Disease that affects the macula of the retina, causing blurry vision and, potentially, blindness.

aging Declines in bodily functions that accumulate with time, ultimately leading to death.

air-displacement plethysmography Procedure used to esti- mate body volume based on the amount of air displaced.

albumin Protein produced in the liver and found in the blood that helps maintain fluid balance.

alcohol dehydrogenase (ADH) One of the alcohol- metabolizing enzymes, found in the stomach and the liver, that converts ethanol to acetaldehyde.

alcohol poisoning State in which the BAC rises to the point that a person’s central nervous system is affected and his or her breathing and heart rate are interrupted.

alcohol tolerance State in which the body has adjusted to long- term alcohol use by becoming less sensitive to the alcohol. More alcohol needs to be consumed in order to get the same euphoric effect.

alcohol use disorder (AUD) Pattern of alcohol intake char- acterized by lack of control over drinking; preoccupation with drinking; continuation of drinking despite negative consequences; tolerance; or withdrawal symptoms when drinking is discontinued.

alcohol Class of organic compounds that contain one or more hydroxyl groups attached to carbons. Examples include ethanol, glycerol, and methanol. Ethanol is often referred to as “alcohol.”

Glossary

G-2 Glossary

alcoholic hepatitis Stage 2 of alcoholic liver disease, in which the liver becomes inflamed.

alcoholic liver disease Degenerative liver condition that occurs in three stages: (1) fatty liver, (2) alcoholic hepatitis, and (3) cirrhosis.

alcoholism Chronic disease influenced by genetic, psychosocial, and environmental factors and characterized by a level of alcohol intake that causes physical, mental, social, and sometimes legal problems.

aldosterone Hormone secreted from the adrenal glands in response to reduced blood volume; signals the kidneys to reab- sorb sodium, which increases blood volume and blood pressure.

alkalosis Condition in which the blood pH is too low due to a low concentration of hydrogen ions.

allergen Substance, such as wheat protein, that causes an allergic reaction.

alpha-ketoglutarate Compound that participates in the forma- tion of nonessential amino acids during transamination.

alpha-linolenic acid Polyunsaturated essential fatty acid; part of the omega-3 fatty acid family.

alpha-tocopherol (𝛂-tocopherol) Most active form of vitamin E in the body.

Alzheimer’s disease Progressive and irreversible type of dementia characterized by distinct changes in brain tissue.

amenorrhea Absence of menstruation for at least three con- secutive cycles.

amine group Nitrogen-containing compound (NH2) connected to the central carbon of an amino acid.

amino acid pools Limited supplies of amino acids that accumu- late in the blood and cells; amino acids are pulled from the pools and used to build new proteins.

amino acid score Composition of essential amino acids in a protein compared with a standard, usually egg protein.

amino acids Fundamental units of proteins; composed of car- bon, hydrogen, oxygen, and nitrogen.

amylopectin Branched chain of polysaccharides found in starch.

amylose Straight chain of polysaccharides found in starch.

anabolic Energy-requiring process in which smaller molecules are combined to form larger molecules.

anaerobic Reaction that does not require oxygen.

anaphylaxis Severe, life-threatening allergic reaction involving a sudden drop in blood pressure and constriction of the airways in the lungs, which inhibits the ability to breathe.

anencephaly Neural tube defect that results in the absence of major parts of the brain.

angiotensin II Blood protein that causes vasoconstriction and triggers the release of aldosterone from the adrenal glands, which raises blood pressure.

anions Negatively charged ions.

anorexia nervosa Eating disorder in which people intentionally starve themselves, causing extreme weight loss.

antibiotic-resistant bacteria Bacteria that have developed a resistance to an antibiotic such that they are no longer affected by antibiotic medication.

antibiotics Drugs that kill or slow the growth of bacteria.

antibodies Proteins that identify and participate in the destruc- tion of pathogens as part of the body’s immune response.

antidiuretic hormone (ADH) Pituitary hormone secreted in response to low blood volume; acts to reduce renal excretion of water, constrict blood vessels, and raise blood pressure; also known as vasopressin.

antimicrobials Substances or a combination of substances, such as disinfectants and sanitizers, that kill or inhibit the growth of microorganisms.

antioxidants Nutrients and phytochemicals that act to neutralize free radicals.

anus Opening of the rectum, or end of the GI tract.

appetite Desire to eat food whether or not there is hunger; a taste for particular foods and cravings in reaction to cues such as the sight, smell, or thought of food.

arachidonic acid Omega-6 fatty acid formed from linoleic acid; used to synthesize the eicosanoids, including leukotrienes, prosta- glandins, and thromboxanes.

ariboflavinosis Deficiency of riboflavin characterized by stoma- titis, glossitis, and cheilosis.

ascorbic acid Active form of vitamin C.

atherosclerosis Narrowing of the coronary arteries due to buildup of debris along the artery walls.

atrophic gastritis Chronic inflammation of the stomach.

atrophy To shrink in size.

attention-deficit/hyperactivity disorder (ADHD) Condition characterized by impulsivity, high distractibility, and hyperactivity; previously known as attention-deficit disorder, or ADD.

avidin Protein in raw egg whites that binds biotin.

B bacteria Single-celled microorganisms without an organized nucleus. Some are benign or beneficial to humans, whereas oth- ers can cause disease.

balance Diet principle of providing the correct proportion of nutrients to maintain health and prevent disease.

bariatric surgery Surgical procedure that promotes weight loss by limiting the amount of food that can be eaten or absorbed.

basal metabolic rate (BMR) Measure of basal metabolism taken when the body is at rest in a warm, quiet environment after a 12-hour fast; expressed as kilocalories per kilogram of body weight per hour.

basal metabolism Amount of energy expended by the body to meet its basic physiological needs, including muscle tone and heart and brain function.

behavior modification Changing behaviors to improve health outcomes. In the case of weight management, it involves

Glossary G-3

identifying and altering eating patterns that contribute to weight gain or impede weight loss.

beriberi Thiamin deficiency that results in weakness; the name translates to “I can not.”

beta-carotene One of the provitamin A carotenoids.

beta-oxidation Series of metabolic reactions in which fatty acids are oxidized to acetyl CoA; also called fatty acid oxidation.

bicarbonate Negatively charged alkali ion produced from bicar- bonate salts; during digestion, bicarbonate ions released from the pancreas neutralize HCl in the duodenum.

bile Secretion produced by the liver, stored in the gallbladder, and released into the duodenum to emulsify dietary fat.

binders Compounds such as oxalates and phytates that bind to minerals in foods and reduce their bioavailability.

binge drinking Pattern of consuming five or more alcoholic drinks by men or four or more drinks by women in about 2 hours that raises BAC to 0.08 g/dl or more.

binge eating disorder Eating disorder characterized by recur- rent episodes of binge eating without purging.

bioaccumulate To build up the levels of a substance or chemical in an organism over time, so that the concentration of the chemical is higher than would be found naturally in the environment.

bioavailability Degree to which a nutrient is absorbed from foods and used in the body.

biodiversity Variability among living organisms on the earth, including the variability within and between species and within and between ecosystems.

bioelectrical impedance analysis (BIA) Method used to assess the percentage of body fat by using a low-level electrical current; body fat resists or impedes the current, whereas water and muscle mass conduct electricity.

biotechnology Manipulation of living organisms or their com- ponents to develop or manufacture useful products.

biotinidase Enzyme in the small intestine that releases biotin from food to allow it to be absorbed.

blackout Amnesia for events that occurred while a person was intoxicated.

bleaching Reaction occurring when light enters the eye and interacts with rhodopsin, splitting it into trans-retinal and opsin.

blood alcohol concentration (BAC) Amount of alcohol in the blood. BAC is measured in grams of alcohol per deciliter of blood, usually expressed as a percentage.

blood lipid profile Measurement of blood lipids used to assess cardiovascular risk.

body composition Ratio of fat to lean tissue (muscle, bone, and organs) in the body; usually expressed as percent body fat.

body image How you perceive your physical appearance.

body mass index (BMI) Calculation of body weight in relation- ship to height.

body mass index (BMI) Measurement calculated using the met- ric formula of weight in kilograms divided by height in meters squared; used to determine whether an individual is underweight, at a healthy weight, overweight, or obese.

bolus Soft mass of chewed food.

bomb calorimeter Instrument used to measure the amount of heat released from food during combustion; the amount of heat produced is directly related to the number of kilocalories in a given food.

bone mineral density (BMD) Amount of minerals, in particu- lar calcium, per volume in an individual’s bone.

botanicals Part of a plant, such as its root, that is believed to have medicinal or therapeutic attributes.

botulism A rare but serious paralytic illness caused by a toxin secreted by the bacterium Clostridium botulinum.

bovine growth hormone (BGH) Hormone that is essential for normal growth and development in cattle.

bran Indigestible outer shell of the grain kernel.

breastfeeding Act of feeding an infant milk from a woman’s breast.

brown adipose tissue (BAT) Type of adipose tissue, found primarily in infants, that produces body heat; gets its name from the large number of mitochondria and capillaries responsible for the brown color.

buffers Substances that help maintain the proper pH in a solu- tion by accepting or donating hydrogen ions.

bulimia nervosa Eating disorder characterized by binging (con- suming large quantities of food in a short period of time) and then purging through vomiting or other means.

C calciferol Family of vitamin D compounds.

calcitonin Hormone secreted by the thyroid gland that lowers blood calcium levels.

calcium (Ca2+) One of the most abundant divalent cations found in nature and in the body.

cancer General term for a large group of diseases characterized by uncontrolled growth of abnormal cells.

canning Process of packing food in airtight containers and heat- ing them to a temperature high enough to kill bacteria.

carbohydrate loading Diet and training strategy that maximizes glycogen stores in the body before an endurance event.

carbohydrate-based fat substitutes Substances that use poly- saccharides to retain moisture and provide a fatlike texture.

carboxylation Chemical reaction in which a carboxyl group is added to a molecule.

carcinogen Cancer-causing substance, including tobacco smoke, air and water pollution, ultraviolet radiation, and various chemicals.

carcinogenesis Process of cancer development.

G-4 Glossary

cardiac arrhythmia Disturbance in the beating and rhythm of the heart; can be caused by excessive alcohol consumption.

cardiac myopathy Condition in which the heart becomes thin and weak and is unable to pump blood throughout the body; also called disease of the heart muscle.

cardiorespiratory conditioning Improvements in the delivery of oxygen to working muscles as a result of aerobic activity.

cardiorespiratory endurance Body’s ability to sustain cardiore- spiratory exercise for a prolonged period of time.

cardiovascular disease (CVD) General term for diseases of the heart and blood vessels.

carnitine Vitamin-like substance used to transport fatty acids across the mitochondrial membrane to properly utilize fat.

carotenodermia Presence of excess carotene in the blood, resulting in an orange color to the skin due to excessive intake of carrots or other carotene-rich vegetables.

catabolic Energy-releasing process that breaks larger molecules into smaller parts.

cataract Common eye disorder that occurs when the lens of the eye becomes cloudy.

cations Positively charged ions.

cecum Pouch at the beginning of the large intestine that receives waste from the small intestine.

celiac disease Genetic disease in which a hyperimmune response damages the villi of the small intestine when gluten is consumed.

cell differentiation Process of a less specialized immature cell becoming a specialized mature cell.

cell division Process of dividing one cell into two separate cells with the same genetic material.

cellulose Nondigestible polysaccharide found in plant cell walls.

central or android obesity Excess storage of visceral fat in the abdominal area, indicated by a waist circumference greater than 40 inches in males and 35 inches in females; central obesity increases the risk of heart disease, diabetes, and hypertension.

ceruloplasmin Protein found in the blood that transports copper.

cheilosis Noninflammatory condition of the lips characterized by chapping and fissuring.

chemical digestion Breaking down food through enzymatic reactions.

chief cells Specialized cells in the stomach that secrete pepsino- gen, an inactive form of the protein-digesting enzyme pepsin.

childhood obesity Condition of a child’s having too much body weight for his or her height. Defined as a BMI at or above the 95th percentile.

chloride (Cl−) Major anion in the extracellular fluid.

chlorophyll Green pigment in plants that absorbs energy from sunlight to begin the process of photosynthesis.

cholecalciferol (vitamin D3) Form of vitamin D found in ani- mal foods, supplements, and formed from precalciferol in the skin; absorbed from the skin into the blood.

cholecystokinin (CCK) Hormone released by the duodenum that stimulates the gallbladder to release bile.

cholesterol Common sterol found only in animal products and made in the liver from saturated fatty acids.

choline Member of the B vitamin family that is a component of the phospholipid lecithin.

choline Vitamin-like substance that is a precursor for the neurotransmitter acetylcholine, which is essential for healthy nerves.

chronic dehydration Dehydration over a long period of time.

chronic disease Noncommunicable disease characterized by a slow onset, long duration, and gradual progression.

chronologic age Person’s age in number of years of life.

chylomicron Type of lipoprotein that carries digested fat and other lipids through the lymph system into the blood.

chyme Semiliquid, partially digested food mass that leaves the stomach and enters the small intestine.

ciguatera poisoning Condition caused by marine toxins that are produced by dinoflagellates and have bioaccumulated in fish that the affected person consumes.

cirrhosis Stage 3 of alcoholic liver disease, in which liver cells die and are replaced by scar tissue.

cis Configuration of a fatty acid in which the carbon atoms on each side of the double bond are on the same side.

closed or “coded” dating Refers to the packing numbers that are decodable only by manufacturers and are often found on non- perishable, shelf-stable foods.

clotting factors Substances involved in the process of blood clotting, such as prothrombin and fibrinogen.

coagulation The process of blood clotting.

cobalamin Vitamin involved in energy metabolism and the con- version of homocysteine to methionine; another name for vitamin vitamin B12.

coenzymes Organic substances, often vitamins, that bind to an enzyme to facilitate enzyme activity; unlike enzymes, coenzymes can be altered by the chemical reaction.

coenzymes Substances, such as vitamins or minerals, that facili- tate the activity of enzymes.

cofactor Substance that binds to an enzyme to help catalyze a reaction; generally refers to a metal ion, whereas a coenzyme is usually an organic compound such as a vitamin.

collagen Protein found in connective tissue, including bones, teeth, skin, cartilage, and tendons.

colon Another name for the large intestine.

colostrum Fluid that is expressed from the mother’s breast after birth and before the development of breast milk.

Glossary G-5

community-supported agriculture (CSA) Arrangement where individuals pay a fee to support a local farm, and in exchange receive a weekly or biweekly box of fresh produce from the farm.

complete protein Protein that provides all the essential amino acids, along with some nonessential amino acids. Soy protein and protein from animal sources are complete proteins.

complex carbohydrates Category of carbohydrates that contain many sugar units combined. Oligosaccharides and polysaccharides are complex carbohydrates.

conception Moment when a sperm fertilizes an egg.

condensation Chemical reaction in which two molecules com- bine to form a larger molecule, and water is released.

conditionally essential amino acids Nonessential amino acids that become essential (and must be consumed in the diet) when the body cannot make them.

conditioning Process of improving physical fitness through repeated activity.

cones Light-absorbing cells responsible for color vision.

congeners Fermentation by-products in alcoholic beverages that may contribute to hangover symptoms.

congregate meals Low- or no-cost meals served at churches, synagogues, or other community sites where older adults can receive a nutritious meal and socialize.

consensus Agreed-upon conclusion of a group of experts based on a collection of information.

constipation Infrequent passage of dry, hardened stools.

control group In experimental research, the group that does not receive the treatment but may be given a placebo instead; used as a standard for comparison.

Cori cycle Metabolic pathway in the liver that regenerates glu- cose from lactate released from the muscle.

cortical bone Hard outer layer of bone.

cortisol Hormone produced by the adrenal cortex that stimulates gluconeogenesis and lipolysis.

C-reactive protein (CRP) Protein found in the blood that is released from the cells during inflammation; used as a marker for the presence of atherosclerosis.

creatine phosphate (PCr) Compound that provides a reserve of phosphate to regenerate ADP to ATP.

cretinism Condition caused by a deficiency of thyroid hormone during prenatal development, resulting in abnormal mental and physical development in children.

critical periods Developmental stages during which cells and tissues rapidly grow and differentiate to form body structures.

Crohn’s disease Form of ulcerative colitis in which ulcers form throughout the GI tract and not just in the colon.

cross-breeding Type of biotechnology in which two plants or two animals with different qualities are bred to produce offspring with desired traits from both.

cross-contaminate Transfer of pathogens from a food, utensil, cutting board, kitchen surface, and/or hands to another food or object.

crypts Glands at the base of the villi; they contain stem cells that manufacture young cells to replace the cells of the villi when they die.

cupric copper Oxidized form of copper (Cu+2)

cuprous copper Reduced form of copper (Cu+)

cytochromes Protein complexes that move electrons down the electron transport chain; contain the minerals iron and copper.

D danger zone Range of temperatures between 40° and 140°F at which foodborne bacteria multiplies most rapidly; room tempera- ture falls within the danger zone.

deamination Removal of the amine group from an amino acid.

dehydration Excessive loss of body fluids; usually caused by inadequate fluid intake, diarrhea, vomiting, or excessive sweating.

DeLaney Clause Clause in the Food Additives Amendment mandating that additives shown to cause cancer at any level must be removed from the marketplace.

dementia Disorder of the brain that interferes with a person’s memory, learning, and mental stability.

denature To alter a protein’s secondary, tertiary, or quaternary structure, thereby disabling its function; the amino acids of the primary structure remain linked together by peptide bonds.

dental caries Tooth decay.

deoxyadenosylcobalamin Coenzyme form of vitamin vitamin B12 that converts intermediate substances in the TCA cycle.

developed country Country that is advanced in multiple areas, such as income per capita, life expectancy, rate of literacy, industrial capability, technological sophistication, and economic productivity.

developing country Country that is growing in multiple areas, such as income per capita, life expectancy, rate of literacy, indus- trial capability, technological sophistication, and economic productivity.

diabetes mellitus Medical condition whereby an individual either doesn’t have enough insulin or is resistant to the insulin available, resulting in a rise in blood glucose levels. Diabetes mel- litus is often called diabetes.

diarrhea Abnormally frequent passage of watery stools.

diastolic pressure Bottom number in a blood pressure reading that measures the minimal arterial pressure during relaxation of the heart muscle when the ventricles fill with blood.

dietary fiber Food components that humans cannot digest; most are carbohydrates.

dietary folate equivalents (DFE) Measurement used to express the amount of folate in a food or supplement.

G-6 Glossary

Dietary Guidelines for Americans Guidelines published every 5 years by the Department of Health and Human Services and the United States Department of Agriculture that provide dietary and lifestyle advice to healthy individuals age 2 and older to maintain good health and prevent chronic diseases. They are the basis for the federal food and nutrition education programs.

Dietary Reference Intakes (DRIs) Reference values for nutri- ents developed by the Food and Nutrition Board of the National Academy of Medicine, used to plan and evaluate the diets of healthy people in the United States and Canada. It includes the Estimated Average Requirement (EAR), the Recommended Dietary Allowance (RDA), the Adequate Intake (AI), and the Tolerable Upper Intake Level (UL).

digestion Process that breaks down food into individual mol- ecules small enough to be absorbed through the intestinal wall.

diglyceride Remnant of fat digestion that consists of a glycerol with two attached fatty acids; also the form of fat used as an emul- sifier in food production.

dipeptide Chain of two amino acids joined together by a peptide bond.

direct calorimetry Direct measurement of the energy expended by the body obtained by assessing heat loss;

disaccharide Simple sugar that consists of two sugar units com- bined. The three most common disaccharides are sucrose, lactose, and maltose.

disordered eating Abnormal and potentially harmful eating behaviors that do not meet specific criteria for a clinical eating disorder.

distillation Evaporation and then collection of a liquid by con- densation. Liquors are made using distillation.

diuretics Substances that increase the production of urine; often used as antihypertensive drugs.

diverticula Small bulges at weak spots in the colon wall.

diverticulitis Infection of the diverticula.

diverticulosis Existence of diverticula in the lining of the large intestine or colon.

DNA fingerprinting Technique in which bacterial DNA “gene patterns” (or “fingerprints”) are detected and analyzed to distin- guish between different strains of a bacterium.

double-blind placebo-controlled study Experimental study in which neither the researchers nor the subjects in the study are aware of who is receiving the treatment or the placebo.

dual-energy X-ray absorptiometry (DEXA) Method that uses two low-energy X-rays to measure body density and bone mass.

E Early-childhood caries Tooth decay from prolonged tooth contact with formula, milk, fruit juice, or other sugar-rich liquid offered to an infant in a bottle.

eating disorders Psychiatric illnesses that involve specific abnor- mal eating behaviors.

eclampsia Seizures or coma in a woman with preeclampsia.

edema Accumulation of excess water in the spaces surrounding the cells, which causes swelling of the body tissue.

eicosanoids Hormonelike substances in the body. Prostaglan- dins, thromboxanes, and leukotrienes are all eicosanoids.

eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) EPA (C20:5n–3) and DHA (C22:6n–3) are omega-3 fatty acids that are synthesized in the body and found in cold-water fish. These compounds may be beneficial in reducing heart disease.

electrolytes Ions such as sodium, potassium, chloride, and cal- cium that are able to conduct electrical current when they are dissolved in body water.

electron transport chain Final stage of energy metabolism in which NADH and FADH2 transport high-energy electrons to the protein complexes in the electron transport chain, resulting in the formation of ATP and water.

elimination Excretion of undigested and unabsorbed food through the feces.

elongation Phase of protein synthesis in which the polypeptide chain grows longer by adding amino acids.

embryo Fertilized egg during the third through the eighth week of pregnancy.

emergency kitchen Kitchen or a commercial food service that prepares for natural disasters, emergencies, or terrorist attacks.

emulsifier Compound that keeps two incompatible substances, such as oil and water, mixed together.

emulsify To break large fat globules into smaller droplets.

endocytosis Type of active transport in which the cell mem- brane forms an indentation, engulfs the substance to be absorbed, and releases it into the interior of the cell.

endosperm Starchy inner portion of a cereal grain.

endotoxins Damaging products released from the cell wall of dead bacteria, such as those in the GI tract. They can travel in the blood to the liver and initiate liver damage.

energy balance State at which energy (kilocalorie) intake from food and beverages is equal to energy (kilocalorie) output for basal metabolism, the thermic effect of exercise, and the thermic effect of food.

energy density Measurement of the kilocalories in a food com- pared with the weight (grams) of the food.

energy gap Difference between the numbers of kilocalories needed to maintain weight before and after weight loss.

energy Capacity to do work.

energy-yielding nutrients Three nutrients that provide energy to the body to fuel physiological functions: carbohydrates, lipids, and protein.

enriched grains Refined grain foods that have folic acid, thia- min, niacin, riboflavin, and iron added.

enteric nervous system Section of the peripheral nervous sys- tem that directly controls the gastrointestinal system.

Glossary G-7

enterocytes Absorptive epithelial cells that line the lumen of the small intestine.

enterogastrones Group of GI tract hormones, produced in the stomach and small intestine, that controls gastric motility and secretions.

enterohepatic circulation Process of recycling bile from the large intestine back to the liver to be reused during fat digestion.

enzymes Proteins in living cells that act as catalysts and control chemical reactions.

enzymes Substances, mostly proteins, that increase the rate of chemical reactions; also called biological catalysts.

epidemiological research Research that studies the variables that influence health in a population; it is often observational.

epigenetics Study of the variety of environmental factors and other mechanisms influencing gene expression.

epiglottis Cartilage at the back of the tongue that closes off the trachea during swallowing.

epinephrine Hormone produced by the adrenal glands that sig- nals the liver cells to release glucose; also referred to as the “fight- or-flight” hormone.

epiphyseal plate Growth plate of the bone; in puberty, growth in this area leads to increases in height.

epithelial tissues Tissues that line body cavities or cover body surfaces.

ergocalciferol (vitamin D2) Form of vitamin D found in plants and dietary supplements.

ergogenic aid Substance, such as a dietary supplement, used to enhance athletic performance.

esophagus Tube that connects the mouth to the stomach.

essential amino acids Nine amino acids that the body cannot synthesize; they must be obtained through dietary sources.

essential fat Component of body fat that is necessary for health and normal body functions; includes the fat stored in the bone marrow, heart, lungs, liver, spleen, kidneys, intestines, muscles, and the lipid-rich tissues of the central nervous system.

essential fatty acids Two polyunsaturated fatty acids that the body cannot make and that therefore must be eaten in foods: lin- oleic acid and alpha-linolenic acid.

essential nutrients Nutrients that must be consumed from foods because they cannot be made in the body in sufficient quan- tities to meet its needs and support health.

Estimated Average Requirement (EAR) Average daily amount of a nutrient needed by 50 percent of the individuals in a similar age and gender group.

Estimated Energy Requirement (EER) Amount of daily energy to maintain a healthy body weight and meet energy needs based on age, gender, height, weight, and activity level.

estimated energy requirement (EER) Average kilocalorie intake that is estimated to maintain energy balance based on a person’s gender, age, height, body weight, and level of physical activity.

ethanol Type of alcohol, specifically ethyl alcohol (C2H5OH), found in alcoholic beverages such as wine, beer, and liquor.

exchange lists Diet-planning tool that groups foods together based on their carbohydrate, protein, and fat content. One food on the list can be exchanged for another food on the same list.

exercise Any type of structured or planned physical activity.

experimental group In experimental research, the group of participants given a specific treatment, such as a drug, as part of the study.

experimental research Research involving at least two groups of subjects receiving different treatments.

extracellular fluid (ECF) Water found outside the cell, includ- ing the intravascular fluid and the interstitial fluid.

F facilitated diffusion Movement of substances across a cell membrane with the help of a carrier protein along their concen- tration gradient.

fad diet Diet that promises rapid weight loss via a method that is typically unproven and unhealthy.

famine Severe shortage of food caused by weather-related crop destruction, poor agricultural practices, pestilence, war, or other factors.

farm-to-table continuum Illustrates the roles that farmers, food manufacturers, food transporters, retailers, and consumers play in ensuring that the food supply, from the farm to the plate, remains safe.

fat substitutes Substances that replace added fat in foods; pro- vide the creamy properties of fat for fewer kilocalories and total fat grams.

fat-based substitutes Substances that resemble triglycerides and are either chemically synthesized or derived from conventional fats and oils by enzymatic modification.

fat-soluble vitamins Vitamins that dissolve in fat and can be stored in the body.

fatty acid Most basic unit of triglycerides and phospholipids; fatty acids consist of carbon chains ranging from 2 to 80 carbons in length.

fatty liver Stage 1 of alcoholic liver disease, in which fat begins to build up in the liver cells.

fecal-to-oral transmission Spread of pathogens by putting something in the mouth, such as hands or food, that has been in contact with infected stool.

ferment (fermentation) Process by which yeast converts sugars in grains or fruits into ethanol and carbon dioxide.

ferment To metabolize sugar into carbon dioxide and other gases.

ferric iron Oxidized form of iron (Fe+3)

ferritin Protein that stores iron in the intestine.

ferroportin Protein found on the basolateral surface of the enterocyte that transports iron out of the enterocyte into the portal vein.

G-8 Glossary

ferrous iron Reduced form of iron (Fe+2)

fetal alcohol spectrum disorders (FASDs) Range of condi- tions that can occur in children who are exposed to alcohol in utero.

fetal alcohol syndrome (FAS) Most severe of the fetal alcohol spectrum disorders (FASDs); children with FAS display physical, mental, and behavioral abnormalities.

fetus Developing embryo that is at least 8 weeks old.

flatulence Production of excessive gas in the stomach or the intestines.

flavin adenine dinucleotide (FAD) Electron carrier similar to NAD that picks up a hydrogen ion from the TCA cycle and carries it to the electron transport chain.

flavin mononucleotide (FMN) Coenzyme form of riboflavin, which functions in the electron transport chain.

flavonoids Phytochemicals found in fruits, vegetables, tea, nuts, and seeds that have antioxidant properties and neutralize free radicals.

flavoproteins Protein complexes that move electrons down the electron transport chain; contain the B vitamin riboflavin.

flexibility Ability to move joints freely through a full and normal range of motion.

fluoroapatite Crystalline structure that results when hydroxyapa- tite has been changed by exposure of the tooth to fluoride.

fluorosis Condition caused by excess amounts of fluoride, resulting in mottling of the teeth.

folate The B vitamin that functions as a coenzyme in cell growth and reproduction.

folic acid Form of folate often used in vitamin supplements and fortification of foods.

food additives Substances added to food that affect its quality, flavor, freshness, and/or safety.

food allergens Proteins that are not broken down by cooking or digestion and enter the body intact, causing an adverse reaction by the immune system of a susceptible individual.

food allergy Abnormal reaction by the immune system that occurs reproducibly in response to consumption of a particular food.

food deserts Parts of the country, usually impoverished areas, where fresh fruits, vegetables, and other healthful whole foods are scarce, largely due to a lack of grocery stores, farmers’ markets, and healthy-food providers.

food insecurity Limited or uncertain access to adequate food within a household.

food intolerance Adverse reaction to a food that does not involve an immune response.

food jag Period of time in which a child will eat only one food or a few limited foods meal after meal.

food pantry Community food assistance location where food is provided to needy individuals and families.

food preservation Treatment of foods to reduce deterioration and spoilage and help prevent the multiplication of pathogens that can cause foodborne illness.

Food Safety Initiative (FSI) Coordinates the research, surveil- lance, inspection, outbreak response, and educational activities of the various government agencies that work together to safeguard food.

food security Household-level economic and social condition characterized by reliable access to adequate amounts of healthy foods.

food system All processes and infrastructure involved in feeding a population: growing, harvesting, processing, packaging, trans- porting, marketing, and consuming food.

foodborne illness Sickness caused by consuming pathogen- or toxin-containing food or beverages. Also known as foodborne disease or food poisoning.

fortified foods Foods with added vitamins and minerals; forti- fied foods often contain nutrients that are not naturally present in the food or that are in higher amounts than the food contains naturally.

free radicals Atoms or molecules that have an unpaired electron and are thus chemically unstable and destabilizing.

fructose Sweetest of all the monosaccharides; also known as fruit sugar or levulose.

functional fiber Nondigestible polysaccharides that are added to foods because of a specific desired effect on human health.

functional foods Foods that may provide additional health ben- efits beyond their basic nutrient value.

fungicides Chemicals used to kill mold.

G galactose Monosaccharide that links with glucose to create the disaccharide found in dairy foods.

galactosemia Genetic disorder characterized by high levels of galactose in the blood; due to the inability to convert galactose to glucose.

gallbladder Pear-shaped organ that stores and concentrates bile produced by the liver and secretes it through the common bile duct into the small intestine.

gallstones Stones formed from cholesterol in the gallbladder or bile duct.

gastric bypass surgery Type of bariatric surgery that reduces the functional volume of the stomach to minimize the amount of food eaten. Such surgeries are sometimes used to treat extreme obesity.

gastric inhibitory peptide (GIP) Hormone produced by the small intestine that slows the release of chyme from the stomach.

gastric pits Indentations or small pits in the stomach lining where the gastric glands are located; gastric glands produce gas- tric juices.

gastrin Hormone released from the stomach that stimulates the release of acid.

Glossary G-9

gastritis Inflammation of the lining in the stomach.

gastroenteritis Inflammation of the lining of the stomach and intestines; also known as stomach flu.

gastroesophageal reflux disease (GERD) Chronic condition characterized by the backward flow of stomach contents into the esophagus, resulting in heartburn.

gastrointestinal (GI) tract Tubular organ system including the mouth, pharynx, esophagus, stomach, and small and large intes- tines, by means of which food is digested, nutrients absorbed, and wastes expelled.

gene expression Processing of genetic information to create a specific protein.

gene–environment interaction Interaction of genetics and environmental factors that increases the risk of obesity in sus- ceptible individuals.

generally recognized as safe (GRAS) Designation given by the FDA to substances intentionally added to food, indicating that the substance is considered safe by experts and is exempted from further testing.

genes A segment of DNA that codes for a protein; genes are inherited from our parents and determines a variety of characteristics.

genetic engineering (GE) Biological technique that isolates and manipulates the genes of organisms to produce a targeted, modified product.

genetically modified organisms (GMOs) Organisms that have been genetically engineered to contain both original and foreign genes.

genome Total genetic information of an organism stored in the DNA of its chromosomes.

germ Vitamin-rich embryo, or seed, of a grain.

gestational diabetes Form of diabetes that may develop during pregnancy in women who were not previously diagnosed with diabetes.

gestational hypertension Hypertension occurring during preg- nancy in a woman without prior history of high blood pressure.

ghrelin Hormone produced in the stomach that stimulates hunger.

GI flora Microorganisms that live in the GI tract of humans and animals.

glossitis Inflammation of the tongue.

glucagon Hormone secreted from the alpha cells of the pan- creas that stimulates glycogenolysis and gluconeogenesis to increase blood levels of glucose.

glucogenic amino acids Amino acids that can be used to form glucose through gluconeogenesis.

gluconeogenesis Creation of glucose from noncarbohydrate sources, predominantly protein.

glucose Primary monosaccharide and primary energy source for the body.

glycemic index (GI) Rating scale of the likelihood of foods to increase the levels of blood glucose and insulin.

glycemic load (GL) Amount of carbohydrate in a food multi- plied by the amount of the glycemic index of that food.

glycerol Three-carbon backbone of a triglyceride.

glycogen storage disease Genetic disorder characterized by a lack of glucose 6-phosphatase, which impairs the body’s ability to break down glycogen.

glycogen Storage form of glucose in animals, including humans.

glycogenesis Process of assembling excess glucose into glyco- gen in the liver and muscle cells.

glycogenolysis Hydrolysis of glycogen to release glucose.

glycolysis Breakdown of glucose; for each molecule of glucose, two molecules of pyruvate and two ATP molecules are produced.

glycosidic bond Bond that forms when two sugar molecules are joined together during condensation.

goblet cells Cells throughout the GI tract that secrete mucus.

goiter Enlargement of the thyroid gland, mostly due to iodine deficiency.

goitrogens Substances in food that reduce the utilization of iodine by the thyroid gland, resulting in goiter.

growth charts Series of percentile curves that illustrate the dis- tribution of selected body measurements in U.S. children.

growth hormone Hormone that regulates glucose metabolism by increasing glycogenolysis and lipolysis.

growth spurt Rapid increase in height and weight.

growth stunting Impaired growth and development caused by undernutrition primarily in childhood. Once growth stunting occurs, it is usually permanent.

gynoid obesity Excessive storage of body fat in the thighs and hips of the lower body.

H hangover Collective term for the unpleasant symptoms, such as a headache and dizziness, that occur after drinking an excessive amount of alcohol; many of the symptoms are caused by high levels of acetaldehyde in the blood.

healthy weight Body weight in relationship to height that doesn’t increase the risk of developing any weight-related health problems or diseases. A BMI between 18.5 and 24.9 is considered healthy.

heart attack Permanent damage to the heart muscle that results from a sudden lack of oxygen-rich blood; also called a myocardial infarction (MI).

heme iron Iron that is part of a heme group found in hemoglo- bin in the blood, myoglobin in muscles, and in the mitochondria as part of the cytochromes.

hemochromatosis Blood disorder characterized by the retention of an excessive amount of iron.

hemochromatosis Genetic disorder that causes the body to store excessive amounts of iron.

G-10 Glossary

hemoglobin Oxygen-carrying, heme-containing protein found in red blood cells.

hemolytic uremic syndrome Rare condition that can be caused by E. coli O157:H7 and results in the destruction of red blood cells and kidney failure. Very young children and older adults are at a higher risk of developing this syndrome.

hemopoiesis Formation of red blood cells.

hemorrhage Excessive bleeding or loss of blood.

hemorrhoid Swelling in the veins of the rectum and anus.

hemosiderin Protein that stores iron in the body.

hepatic portal vein Large vein that connects the GI tract to the liver and transports newly absorbed water-soluble nutrients.

hepatic vein Vein that carries the blood received from the hepatic portal vein away from the liver.

hepcidin Hormone produced in the liver that regulates the absorption and transport of iron.

hephaestin Copper-containing enzyme that catalyzes the conversion of ferrous to ferric iron before attaching to transferrin for transport.

herbicides Substances that are used to kill and control weeds.

hexose Sugar that contains six carbons; glucose, galactose, and fructose are all hexoses.

high-density lipoproteins (HDLs) Lipoproteins that remove cholesterol from the tissues and deliver it to the liver to be used as part of bile and/or to be excreted from the body. Because of this, HDL is known as the “good” cholesterol.

High-intensity interval training (HIIT) Interval training that includes short periods of intense anaerobic exercise alternating with less intense recovery periods.

high-pressure processing (HPP) Method used to pasteurize foods by exposing the items to pulses of high pressure, which destroys the microorganisms that are present.

homocystinuria Genetic disorder characterized by the inability to metabolize the essential amino acid methionine.

hormone-sensitive lipase Enzyme that catalyzes lipolysis of triglycerides.

host Living plant or animal (including a human) that a virus infects for the sake of reproducing.

hunger Strong sensation indicating a physiological need for food.

hydrochloric acid (HCl) Strong acid produced in the stomach that aids in digestion.

hydrogenation Adding hydrogen to an unsaturated fatty acid to make it more saturated and solid at room temperature.

hydrolysis Chemical reaction that breaks the bond between two molecules with water. A hydroxyl group is added to one molecule and a hydrogen ion is added to the other molecule.

hydrophobic “Water fearing.” In nutrition, the term refers to compounds that are not soluble in water.

hydrostatic weighing Method used to assess body volume by underwater weighing.

hydroxyapatite Crystalline salt structure that provides strength in bones and teeth. Calcium and phosphorus are the main miner- als found in the structure.

hypercalcemia Abnormally high levels of calcium in the blood.

hypercalcemia Chronically high amount of calcium in the blood.

hyperchloremia Abnormally high level of chloride in the blood.

hyperemesis gravidarum Excessive vomiting during pregnancy that can lead to dehydration and loss of electrolytes.

hyperkalemia Abnormally high levels of potassium in the blood.

hypernatremia Excessive amounts of sodium in the blood.

hyperphenylalanemia Elevated levels of blood phenylalanine due to a lack of the enzyme phenylalanine hydroxylase.

hyperphosphatemia Abnormally high level of phosphorus in the blood.

hyperplasia Increase in the number of cells due to cell division.

hypertension High blood pressure; defined as a systolic blood pressure higher than 140 mm Hg and/or a diastolic blood pres- sure greater than 90 mm Hg.

hyperthermia Rise in body temperature above normal.

hypertonic Having a high solute concentration.

hypertriglyceridemia Presence of high concentrations of tri- glycerides in the blood. Defined as triglyceride concentrations between 400 and 1,000 milligrams per deciliter.

hypertrophy Increase in size; in adipocytes, hypertrophy refers to the increase in size of the cells.

hypervitaminosis Condition resulting from the presence of excessive amounts of vitamins in the body; also referred to as vitamin toxicity.

hypervitaminosis A Serious condition in which the liver accu- mulates toxic levels of vitamin A.

hypervitaminosis D Condition resulting from excessive amounts of vitamin D in the body.

hypocalcemia Abnormally low levels of calcium in the blood.

hypochloremia Abnormally low level of chloride in the blood.

hypoglycemia Blood glucose level that drops to lower than 70 mg/dl.

hypokalemia Dangerously low level of blood potassium.

hyponatremia Dangerously low level of sodium in the blood that can result from dilution or depletion of sodium.

hypophosphatemia Abnormally low level of phosphorus in the blood.

hypothermia Drop in body temperature to below normal.

hypothesis Idea or explanation proposed by scientists based on observations or known facts.

hypotonic Having a low solute concentration.

hypovolemia Low blood volume.

Glossary G-11

I ileocecal valve Sphincter that separates the small intestine from the large intestine.

immunity State of having built up memory immune cells that target a particular pathogen so that any subsequent encoun- ter with that pathogen prompts rapid production of specific antibodies.

impaired glucose tolerance Condition whereby a fasting blood glucose level is higher than normal, but not high enough to be classified as having diabetes mellitus. Also called prediabetes.

incomplete protein Protein that is low in one or more of the essential amino acids. Proteins from plant sources tend to be incomplete.

indirect calorimetry Indirect measurement of energy expendi- ture obtained by measuring the amount of oxygen consumed and carbon dioxide produced.

infancy Age range from birth to 12 months.

inflammatory bowel disease (IBD) Chronic inflammation throughout the GI tract.

inorganic Describing elements or compounds that do not con- tain carbon.

inositol Water-soluble compound synthesized in the body that maintains healthy cell membranes.

insecticides Pesticides used to kill insects.

insensible water loss Loss of body water that goes unnoticed, such as by exhalation during breathing and the evaporation of water through the skin.

insoluble fiber Type of fiber that isn’t dissolved in water or fer- mented by intestinal bacteria.

insulin Hormone secreted from the beta cells of the pancreas that stimulates the uptake of glucose from the blood into the cells.

insulin resistance Inability of the cells to respond to insulin.

integrated pest management (IPM) Agricultural technique that uses the most economical and the least harmful methods of pest control to minimize risk to consumers, crops, and the environment.

intensity Level of difficulty of an activity.

intentional food additives Substances added intentionally to foods to improve food quality.

international units (IU) System of measurement of a biologically active ingredient such as a vitamin that produces a certain effect.

interstitial fluid Tissue fluid; the fluid that surrounds cells.

intestinal permeability Condition in which the junctions between enterocytes allow large molecules to enter the blood- stream; also called leaky gut syndrome.

intracellular fluid (ICF) Fluid found in the cytoplasm within cells.

intravascular fluid Fluid found inside the blood and lymphatic vessels.

intrinsic factor (IF) Glycoprotein secreted by the stomach that facilitates the absorption of vitamin vitamin B12 iodide Ionized form of iodine in the body (I-)

iodopsin Compound found in the cones of the eye that is needed for color vision.

iron-deficiency anemia Type of anemia due to a lack of dietary iron or excessive loss of blood.

irradiation Process in which foods are placed in a shielded chamber, called an irradiator, and subjected to a radiant energy source; kills specific pathogens in food by breaking up the cells’ DNA.

irritable bowel syndrome (IBS) Intestinal disorder resulting in abdominal discomfort, pain, diarrhea, constipation, and bloating; the cause is unknown.

isoflavones Naturally occurring phytoestrogens, or weak plant estrogens, that function in a similar fashion to the hormone estro- gen in the human body.

J jaundice Yellowish coloring of the skin due to the presence of bile pigments in the blood.

K keratinization Accumulation of the protein keratin in epithelial cells, forming hard, dry cells unable to secrete mucus; due to vitamin A deficiency.

Keshan disease Disease related to a deficiency of selenium.

ketoacidosis Form of metabolic acidosis, or pH imbalance due to excess acid, that occurs when excess ketone bodies are present in the blood; most often seen in individuals with untreated type I diabetes.

ketogenesis Formation of ketone bodies from excess acetyl CoA.

ketogenic Describing molecules that can be transformed into ketone bodies.

ketone bodies By-products of the incomplete breakdown of fat.

ketosis Condition of increased ketone bodies in the blood.

kilocalorie Amount of energy required to raise the tempera- ture of 1 kilogram of water 1 degree centigrade; used to express the measurement of energy in foods; 1 kilocalorie is equal to 1,000 calories.

kwashiorkor State of PEM in which there is a severe deficiency of dietary protein.

L laboratory experiment Scientific experiment conducted in a laboratory; some involve animals.

lactate Three-carbon compound generated from pyruvate when mitochondria lack sufficient oxygen.

G-12 Glossary

lactation Production of milk in a woman’s body after childbirth and the period during which it occurs.

lactose intolerance When maldigestion of lactose results in symptoms such as nausea, cramps, bloating, flatulence, and diarrhea.

lactose maldigestion Inability to digest lactose due to low levels of the enzyme lactase.

lactose Disaccharide composed of glucose and galactose; also known as milk sugar.

lanugo Very fine, soft hair typically found on a newborn or a person who is malnourished.

large intestine Lowest portion of the GI tract, where water and electrolytes are absorbed and waste is eliminated.

lean body mass (LBM) Total body weight minus the fat mass; consists of water, bones, vital organs, and muscle; metabolically active tissue in the body.

least developed country Country that shows little growth in multiple areas, such as income per capita, life expectancy, rate of literacy, industrial capability, technological sophistication, and eco- nomic productivity.

lecithin Phospholipid made in the body that is integral in the structure of cell membranes; also known as phosphatidylcholine.

letdown response Release of milk from the mother’s breast to feed a nursing baby.

licensed dietitian nutritionist (LDN) Individual who has met specified educational and experience criteria deemed by a state licensing board necessary to be considered an expert in the field of nutrition. An RDN would meet all the qualifications to be an LDN.

life expectancy Average length of life for a population of individuals.

lifespan Maximum age to which members of a species can live.

lignin Noncarbohydrate form of dietary fiber that binds to cel- lulose fibers to harden and strengthen the cell walls of plants.

limiting amino acid Essential amino acid that is in the shortest supply, relative to the body’s needs, in an incomplete protein

linoleic acid Polyunsaturated essential fatty acid; part of the omega-6 fatty acid family.

lipases Group of lipid-digesting enzymes.

lipid Category of carbon, hydrogen, and oxygen compounds that are insoluble in water.

lipogenesis Process that converts excess glucose into fat for storage.

lipoic acid Vitamin-like substance used in energy production; may also act as an antioxidant.

lipoprotein lipase (LPL) Enzyme that hydrolyzes triglycerides in lipoproteins into three fatty acids and glycerol.

lipoprotein Capsule-shaped transport carrier that enables fat and cholesterol to travel through the lymph and blood.

liver Accessory organ of digestion located in the upper abdomen and responsible for the synthesis of bile, the processing of nutri- ents, the metabolism of alcohol, and other functions.

locavore Person who eats locally grown food whenever possible.

long-chain fatty acids Fatty acids with a chain of more than 12 carbons.

longevity Duration of an individual’s life.

low birthweight Describes a baby weighing less than 51�2 pounds at birth.

low-density lipoproteins (LDLs) Lipoproteins that deposit cholesterol in the walls of the arteries. Because this can lead to heart disease, LDL is referred to as the “bad” cholesterol.

lower esophageal sphincter (LES) Muscular ring located between the base of the esophagus and the stomach.

Lp(a) protein Lipoprotein containing LDL cholesterol found in the blood; has been correlated to increased risk of heart disease.

lumen Channel or inside space of a vessel such as the intestine or artery.

lymphatic system System of interconnected vessels that con- tains lymph fluid in which fat-soluble nutrients are carried; also includes bone marrow, lymph nodes, and other tissues and organs that produce and store defensive cells.

M macrocytic anemia Condition that results in abnormally large, pale, and fewer than normal red blood cells.

macronutrients Essential nutrients, including water and the energy-containing carbohydrates, lipids, and proteins that the body needs in large amounts.

macrosomia Term for a large newborn, weighing more than 8 pounds, 13 ounces.

magnesium (Mg+2) Major divalent cation in the body.

major minerals Minerals found in the body in amounts greater than 5 grams; also referred to as macrominerals.

major minerals Minerals needed in amounts greater than 100 milligrams per day. These include sodium, chloride, potassium, calcium, phosphorus, magnesium, and sulfur.

malabsorption Condition characterized by impaired absorption of nutrients through the gastrointestinal tract.

malnourished Characterized by an inappropriate level of essen- tial nutrients to maintain health; overnourishment and undernour- ishment are forms of malnutrition.

maltose Disaccharide composed of two glucose units joined together.

maple syrup urine disease (MSUD) Genetic disorder charac- terized by the inability to metabolize branched-chain amino acids; symptoms include a maple syrup smell in the urine.

marasmus State of PEM in which there is a severe deficiency of kilocalories, which perpetuates wasting; also called starvation.

Glossary G-13

marine toxins Chemicals that occur naturally and contaminate some fish.

mass movement (mass peristalsis) Strong, slow peristaltic move- ments, occurring only three or four times a day within the colon, that force waste toward the rectum.

mast cells Cells in connective tissue to which antibodies attach, setting the stage for potential future allergic reactions.

mastication Chewing food.

Meals on Wheels Program that delivers nutritious meals to homebound older adults.

mechanical digestion Breaking down food by chewing, grind- ing, squeezing, and moving it through the GI tract by peristalsis and segmentation.

medical nutrition therapy Integration of nutrition counseling and dietary changes, based on individual medical and health needs, to treat a patient’s medical condition.

medium-chain fatty acids Fatty acids with a chain of 8–12 carbons.

megadose Amount of a vitamin or mineral that’s at least 10 times the amount recommended in the DRI.

menaquinone (vitamin K2) The form of vitamin K produced by bacteria in the colon.

menarche Onset of menstruation.

Menkes’ disease Genetic disorder that interferes with copper absorption.

messenger RNA (mRNA) Type of RNA that copies the genetic information from the DNA and carries it from the nucleus to the ribosomes in the cell.

metabolic pathway Sequence of reactions that convert com- pounds from one form to another.

metabolic programming Process by which the prenatal envi- ronment interacts with genetic and other factors to produce per- manent change; also called fetal programming.

metabolic water Water that is formed in the body as a result of metabolic reactions. Condensation reactions are an example of a chemical reaction that results in the production of water.

metabolism Sum of all chemical reactions in the body.

metalloenzymes Active enzymes that contain one or more metal ions that are essential for their biological activity.

metallothionine Metal-binding protein rich in sulfur-containing amino acids that transports ions.

methylcobalamin Coenzyme form of vitamin vitamin B12 that converts homocysteine to methionine.

micelle Transport carrier in the small intestine that enables fatty acids and other compounds to be absorbed.

microcytic hypochromic anemia Form of anemia in which red blood cells are small and pale in color due to lack of hemoglobin synthesis.

micronutrients Essential nutrients the body needs in smaller amounts: vitamins and minerals.

microsomal ethanol oxidizing system (MEOS) Second major enzyme system in the liver that metabolizes alcohol.

microsomes Small vesicles in the cytoplasm of liver cells where oxidative metabolism of alcohol takes place.

microvilli Tiny projections on the villi in the small intestine.

milestones Objectives or significant events that occur during development.

mineralization Process of adding minerals, including calcium and phosphorus, to the collagen matrix in the bone, which makes the bone strong and rigid.

minerals Inorganic elements essential to the nutrition of humans.

mitochondrion Cellular organelle that releases energy from carbohydrates, proteins, and fats to make ATP; pl. mitochondria.

moderate drinking According to the Dietary Guidelines for Ameri- cans, up to one drink per day for women and up to two drinks a day for men.

moderate Diet principle of providing reasonable but not exces- sive amounts of foods and nutrients.

modified atmosphere packaging (MAP) Food preservation technique that changes the composition of the air surrounding the food in a package to extend its shelf-life.

molds Microscopic fungi that live on plant and animal matter; some can produce mycotoxins, which are harmful.

monoglyceride Remnant of fat digestion that consists of a glycerol with only one fatty acid attached to one of the three carbons.

monosaccharide Simple sugar that consists of a single sugar unit. The three most common monosaccharides are glucose, fruc- tose, and galactose.

monosodium glutamate (MSG) Sodium salt of glutamic acid, used as a flavor enhancer.

monounsaturated fatty acid (MUFA) Fatty acid that has one double bond.

mucus Secretion produced throughout the GI tract that moist- ens and lubricates food and protects membranes.

muscular endurance Ability of the muscle to produce pro- longed effort.

muscular strength Greatest amount of force exerted by the muscle at one time.

myelin sheath Tissue that surrounds nerves and speeds the transmission of nerve impulses.

myoglobin Oxygen-carrying, heme-containing protein found in muscle cells.

MyPlate Icon that serves as a reminder for healthy eating and a website providing nutritional information and educational tools based on the Dietary Guidelines for Americans and the Dietary Refer- ence Intakes (DRIs).

G-14 Glossary

N negative energy balance State in which energy intake is less than energy expenditure; over time, this results in weight loss.

neural tube defects Any major birth defect of the central ner- vous system, including the brain, caused by failure of the neural tube to properly close during embryonic development.

niacin equivalents (NE) Measurement that reflects the amount of niacin and tryptophan in foods that can be used to synthesize niacin.

nicotinamide adenine dinucleotide (NAD + ) Coenzyme form of niacin that functions as an electron carrier and can be reduced to NADH during metabolism.

nicotinamide adenine dinucleotide phosphate (NADP + ) Coenzyme form of niacin that functions as an electron carrier and can be reduced to NADPH during metabolism.

night blindness Inability to see in dim light or at night due to a deficiency of retinal in the retina.

nitrites and nitrates Substances that can be added to foods to function as a preservative and to give meats such as hot dogs and luncheon meats a pink color.

nitrogen balance Difference between nitrogen intake and nitro- gen excretion.

non-celiac gluten sensitivity (NCGS) Reaction to eating foods that contain gluten when celiac disease has been ruled out. Symp- toms vary widely but may include abdominal pain, fatigue, head- aches, rashes, or mental confusion.

nonessential amino acids Eleven amino acids the body can syn- thesize and that therefore do not need to be consumed in the diet.

nonessential nutrients Nutrients that can be made in sufficient quantities in the body to meet the body’s requirements and sup- port health.

nonexercise activity thermogenesis (NEAT) Energy expended for all activities not related to sleeping, eating, or exer- cise, including fidgeting, performing work-related activities, and playing.

nonheme iron Iron that is not attached to heme.

norepinephrine Hormone produced by the adrenal glands that stimulates glycogenolysis and gluconeogenesis.

normal blood pressure Systolic blood pressure less than 120 mm Hg (the top number) and a diastolic blood pressure less than 80 mm Hg (the bottom number); referred to as 120/80.

norovirus Most common type of virus that causes foodborne illness; can cause gastroenteritis, or the “stomach flu.”

nutrient density Measurement of the nutrients in a food com- pared with the kilocalorie content; nutrient-dense foods are high in nutrients and low in kilocalories.

nutrient requirements Amounts of specific nutrients needed to prevent malnutrition or deficiency; reflected in the DRIs.

nutrients Compounds in foods that sustain body processes. There are six classes of nutrients: carbohydrates, fats (lipids), proteins, vitamins, minerals, and water.

nutrition Science that studies how nutrients and other compo- nents of foods nourish the body and affect body functions and overall health.

Nutrition Facts panel Area on the food label that provides a list of specific nutrients obtained in one serving of the food.

nutrition transition Shift in dietary consumption and energy expenditure that may occur as people in developing countries shift from their traditional diet to diets higher in sugar, fat, and animal-based foods.

nutritional genomics Study of the relationship between genes, gene expression, and nutrition.

nutritionist Generic term with no recognized legal or profes- sional meaning. Some people may call themselves a nutritionist without having any credible training in nutrition.

O obese Condition of excess body weight due to an abnormal accumulation of stored body fat; a BMI of 30 or more is con- sidered obese.

observational research Research that involves systematically observing subjects to see if there is a relationship to certain outcomes.

oils Lipids that are liquid at room temperature.

oligosaccharides Three to 10 units of monosaccharides combined.

omega-3 fatty acid Family of polyunsaturated fatty acids with the first double bond located at the third carbon from the omega end.

omega-6 fatty acid Family of polyunsaturated fatty acids with the first double bond located at the sixth carbon from the omega end.

open dating Typically found on perishable items such as meat, poultry, eggs, and dairy foods; must contain a calendar date.

organic Being free of chemical-based pesticides, synthetic fertil- izers, irradiation, and bioengineering; a USDA-accredited certify- ing inspector must certify organic foods.

organic Describing compounds that contain carbon or carbon– carbon bonds.

organophosphates Group of synthetic pesticides that adversely affect the nervous systems of pests.

osmolality Measurement of the concentration of solutes per kilogram of solvent in a solution.

osmosis Diffusion of water or any solvent across a semiperme- able membrane from an area of lower solute concentration to an area of higher solute concentration.

osmotic gradient Difference in concentration between two solutions on either side of the cell membrane.

osmotic pressure Pressure that prevents the solutes in a solution from drawing water across a semipermeable membrane.

osteomalacia Adult equivalent of rickets, causing muscle and bone weakness and pain.

Glossary G-15

osteopenia Condition in which the bone mineral density is lower than normal but not low enough to be classified as osteoporosis.

osteoporosis Disorder characterized by low bone mineral den- sity, which increases the individual’s risk of fractures.

overexercise Excessive physical activity without adequate rest periods for proper recovery.

overnourished Characterized by an excessive intake of energy or one or more individual nutrients.

overpopulation Condition in which a region has more people than its natural resources can support.

overweight Body weight that increases risk of developing weight-related health problems; defined as having a BMI between 25 and 29.9.

oxaloacetate Starting molecule for the TCA cycle.

oxidative phosphorylation Metabolic pathway in the mitochon- dria in which ATP is formed using energy from the oxidation- reduction reactions in the electron transport chain.

oxidative stress Condition whereby free radicals are being pro- duced in the body faster than they are neutralized.

P pancreas Large gland located behind the stomach that releases digestive enzymes and bicarbonate after a meal. Also secretes the hormones insulin and glucagon, which control blood glucose.

paralytic shellfish poisoning Condition caused by a reddish- brown-colored dinoflagellate that contains neurotoxins.

parasites Organisms that live on or in another organism; obtain their nourishment from their hosts.

parathyroid hormone (PTH) Hormone secreted from the parathyroid glands that activates vitamin D formation in the kidney.

parietal cells Specialized cells in the stomach that secrete the gastric juices hydrochloric acid and intrinsic factor.

passive diffusion Movement of substances across a cell mem- brane along their concentration gradient.

pasteurization Process of heating liquids or food at high tem- peratures to destroy foodborne pathogens.

pathogens Collective term for disease-causing organisms. Patho- gens include microorganisms (viruses, bacteria) and parasites and are the most common source of foodborne illness.

peak bone mass Genetically determined maximum amount of bone mass an individual can build up.

peer-reviewed journal Journal in which scientists publish research findings, after the findings have gone through a rigorous review process by other scientists.

pellagra Disease resulting from a deficiency of niacin or tryptophan.

pepsin Active protease that begins the digestion of proteins in the stomach.

pepsinogen Inactive protease secreted by the chief cells in the stomach; it is converted to the active enzyme pepsin in the pres- ence of HCl.

peptide bonds Bonds that connect amino acids; created when the acid group of one amino acid is joined with the amine group of another through condensation.

peptide YY Hormone produced in the small intestine that reduces hunger.

peptide Chain of amino acids.

percent Daily Values (%DVs) Reference values developed by the Food and Drug Administration and used on the Nutrition Facts panel to describe the percentage of a daily nutrient intake provided in one serving of the food.

percentile Most commonly used clinical indicator to assess the size and growth patterns of children in the United States. An indi- vidual child is ranked according to the percentage of the reference population he or she equals or exceeds.

peripheral neuropathy Damage to the peripheral nerves caus- ing pain, numbness, and tingling in the feet and hands and muscle weakness.

peristalsis Forward, rhythmic muscular contractions that move food through the GI tract.

pernicious anemia Form of anemia caused by a lack of intrin- sic factor needed for absorption of vitamin vitamin B12 forming large, immature red blood cells.

pernicious anemia Form of macrocytic anemia caused by a lack of intrinsic factor due to either gastritis or an autoimmune disorder.

pesticides Substances that kill or repel pests such as insects, weeds, microorganisms, rodents, or fungi.

pH Measure of the acidity or alkalinity of a solution.

pharynx Area of the GI tract between the mouth and the esoph- agus; also called the throat.

phenylketonuria (PKU) Genetic disorder characterized by the inability to metabolize the essential amino acid phenylalanine.

phospholipids Category of lipids that consists of two fatty acids and a phosphate group attached to a glycerol backbone. Lecithin is an example of a phospholipid found in food and in the body.

phosphorus (P) Second most abundant mineral in the body.

photosynthesis Process by which plants create carbohydrates using the energy from sunlight.

phylloquinone (vitamin K1) The form of vitamin K found in plants.

physical activity Voluntary movement that results in energy expenditure.

physical fitness Ability to perform physical activities requiring cardiorespiratory endurance, muscle endurance, strength, and/ or flexibility, typically acquired through exercise and adequate nutrition.

physiologic age Person’s age estimated in terms of body health, function, and life expectancy.

G-16 Glossary

physiological fuel values Real energy value of foods that are digested and absorbed; adjusted from the results of bomb calo- rimetry because of the inefficiency of the body.

phytochemicals Non-nutritive plant compounds, found in fruits and vegetables, that may play a role in fighting chronic diseases.

phytostanols Type of plant sterol similar in structure to cholesterol.

phytosterols Naturally occurring sterols found in plants.

pica Eating nonfood substances such as dirt and clay.

placebo Inactive substance, such as a sugar pill, administered to a control group during an experiment.

placenta Organ that allows nutrients, oxygen, and waste prod- ucts to be exchanged between a mother and fetus.

plaque Hardened buildup of cholesterol-laden foam cells, plate- lets, cellular waste products, and calcium in the arteries that results in atherosclerosis.

polychlorinated biphenyls (PCBs) Synthetic chemicals that have been shown to cause cancer and other adverse effects on the immune, reproductive, nervous, and endocrine systems in animals; may cause cancer in humans.

polypeptide Chain consisting of 10 or more amino acids joined together by peptide bonds.

polysaccharides Many sugar units combined. Starch, glycogen, and fiber are all polysaccharides.

polyunsaturated fatty acid (PUFA) Fatty acid with two or more double bonds.

portion Quantity of a food usually eaten at one sitting.

positive energy balance State in which energy intake is greater than energy expenditure; over time, this results in weight gain.

postabsorptive state Period when you haven’t eaten for more than 4 hours and the stomach and intestines are empty. Energy needs are met by the breakdown of stores.

potassium (K + ) Main cation in the intracellular fluid.

poverty Lacking the means to provide for material or comfort needs.

prebiotics Nondigestible starch found in plant foods that pro- motes the growth and health of your GI flora.

preeclampsia Serious medical condition developed late in preg- nancy in which hypertension, severe edema, and protein loss occur.

preformed vitamins Vitamins found in food.

pregnancy-induced hypertension High blood pressure result- ing from pregnancy; includes gestational hypertension, preeclamp- sia, and eclampsia.

preschoolers Children 3–5 years old.

preservatives Substances that extend the shelf-life of a product by retarding chemical, physical, or microbiological changes.

primary malnutrition State of being malnourished due to poor diet, consuming either too much or too little of a nutrient or energy.

primary structure First stage of protein synthesis after tran- scription when the amino acids have been linked together with peptide bonds to form a simple linear chain.

prion Short for proteinaceous infectious particle; self-reproduc- ing protein particles that cause degenerative brain diseases.

prior-sanctioned Substances that the FDA had determined were safe for use in foods prior to the 1958 Food Additives Amendment.

probiotics Live microorganisms that, when consumed in ade- quate amounts, confer a health benefit on the host.

progressive overload principle Gradual increase in exercise demands resulting from modifications to the frequency, intensity, time, or type of activity.

prohormone Physiologically inactive precursor to a hormone.

proof Measure of the amount of ethanol contained in alcoholic beverages.

proportionality Relationship of one entity to another. Vegeta- bles and fruits should be consumed in a higher proportion than dairy and protein foods in the diet.

propulsion Process that moves food along the gastrointestinal tract during digestion.

proteases Classification of enzymes that catalyze the hydrolysis of proteins.

protein digestibility corrected amino acid score (PDCAAS) Score measured as a percentage that takes into account both digestibility and amino acid score and provides a good indication of the quality of a protein.

protein turnover Continual process of degrading and synthesiz- ing protein.

protein-based fat substitutes Substances created from the pro- tein in eggs and milk.

protein-energy malnutrition (PEM) Lack of sufficient dietary protein and/or kilocalories.

proteins Large molecules, made up of chains of amino acids, found in all living cells.

provitamin Vitamin precursor that is converted to a vitamin in the body.

provitamin-A carotenoids Group of yellow, red, and orange plant pigments that act as precursors to vitamin A.

puberty Period during which adolescents reach sexual maturity and become capable of reproduction.

public health nutritionists Individuals who may have an under- graduate degree in nutrition but who are not registered dietitian nutritionists.

pyridoxal phosphate (PLP) Active coenzyme form of vitamin vitamin B6 pyruvate Three-carbon molecule formed from the oxidation of glucose during glycolysis.

Glossary G-17

Q quackery Promotion and selling of health products and services of questionable validity. A quack is a person who promotes these products and services in order to make money.

quaternary structure Rod-like or globular structure of a protein formed when two or more polypeptide chains cluster together.

R R protein Protein secreted from the salivary glands that binds vitamin vitamin B12 in the stomach and transports it into the small intestine during digestion.

rancidity Spoiling of lipids through oxidation.

rating of perceived exertion (RPE) Subjective measure of the intensity level of an activity using a numerical scale.

recombinant bovine somatotropin (rbST) Synthetically made hormone identical to a cow’s natural growth hormone, somatotro- pin, that stimulates milk production; also known as rbGH (recombi- nant bovine growth hormone).

Recommended Dietary Allowance (RDA) Recommended daily amount of a nutrient that meets the needs of nearly all indi- viduals (97–98 percent) in a similar age and gender group. The RDA is set higher than the EAR.

rectum Final 8-inch portion of the large intestine.

refined grains Grain foods that are made with only the endo- sperm of the kernel. The bran and germ have been removed dur- ing milling.

registered dietitian nutritionist (RDN) Health professional who is a food and nutrition expert; RDNs obtain a college degree in nutrition from an Academy of Nutrition and Dietetics–accred- ited program and pass a national exam.

relative energy deficiency in sport (RED-S) Syndrome of low energy availability based on the balance between energy intake through food and energy expenditure for daily activities, growth, and training and competition.

renin Enzyme secreted by the kidneys that increases blood vol- ume, vasoconstriction, and blood pressure.

repetition maximum (RM) Maximum amount of weight that can be lifted for a specified number of repetitions.

resistance training Exercising with weights to build, strengthen, and tone muscle to improve or maintain overall fitness; also called strength training.

resistant starch Type of starch that is not digested in the GI tract but has important health benefits in the large intestine.

resting metabolic rate (RMR) Measure of the amount of energy expended by the body at rest and after approximately a 3- to 4-hour fasting period; about 6 percent higher than BMR.

retinal Aldehyde form of preformed vitamin A.

retinoic acid Acid form of preformed vitamin A.

retinoids Term used to describe the family of preformed vitamin A compounds.

retinol activity equivalents (RAE) Unit of measure used to describe the total amount of all forms of preformed vitamin A and provitamin A carotenoids in food.

retinol Alcohol form of preformed vitamin A.

retinyl ester Ester form of preformed vitamin A found in foods and stored in the body.

rhodopsin Compound found in the rods of the eye that is needed for night vision; composed of cis-retinal and the protein opsin.

ribosomes Organelles found in the cytoplasm that read the mRNA and build the protein in the proper sequence during elongation.

rickets Vitamin D deficiency in children resulting in soft bones.

risk assessment Process of determining the potential human health risks posed by exposure to substances such as pesticides.

rodenticides Poisons used to kill rats, mice, and other rodents.

rods Light-absorbing cells responsible for black-and-white vision and night vision.

S saliva Secretion from the salivary glands that softens and lubri- cates food and begins the chemical breakdown of starch.

salivary amylase Digestive enzyme that begins breaking down carbohydrate (starch) in the mouth; other important enzymes dur- ing carbohydrate digestion include pancreatic amylase, maltase, sucrase, and lactase.

salivary glands Cluster of glands located underneath and behind the tongue that release saliva in response to the sight, smell, and taste of food.

sarcopenia Age-related progressive loss of muscle mass, muscle strength, and function.

satiation State of being satisfactorily full during a meal, which inhibits the ability to eat more food.

satiety Feeling of satiation, or “fullness,” after a meal before hunger sets in again.

saturated fatty acid Fatty acid in which all of the carbons are bound with hydrogen.

school-aged children Children between the ages of 6 and 12.

scientific method Process used by scientists to gather and test information for the sake of generating sound research findings.

scombrotoxic fish poisoning Condition caused by consum- ing spoiled fish that contain large amounts of histamines; also referred to as histamine fish poisoning.

scurvy Disease caused by a deficiency of vitamin C and charac- terized by bleeding gums and a skin rash.

secondary malnutrition State of being malnourished due to interference with nutrient absorption or metabolism.

G-18 Glossary

secondary structure Shape of a protein in which hydrogen bonding between carboxyl and amine groups has caused the straight chain to fold and twist.

secretin A hormone secreted from the duodenum that stimulates the stomach to release pepsin, the liver to make bile, and the pan- creas to release digestive juices.

segmentation Muscular contractions of the small intestine that move food back and forth, breaking the mixture into smaller and smaller pieces and combining it with digestive juices.

selectively permeable Characteristic of cell membranes that allows some substances to cross more easily than others.

selenomethionine Amino acid that contains selenium rather than sulfur.

selenoproteins Proteins that contain selenomethionine.

selenosis Presence of toxic levels of selenium.

senescence Another term for aging.

serving size Recommended portion of food that is used as a standard reference on food labels.

set point Weight-control theory proposing that each individual has a genetically established body weight and that significant devi- ation from this point stimulates changes in body metabolism to reestablish the normal weight.

severe obesity Defined as a BMI greater than 40 or more than 100 pounds over ideal body weight.

short-chain fatty acid Fatty acid with a chain of less than eight carbons.

sickle cell anemia Blood disorder caused by a genetic defect that results in the synthesis of hemoglobin S, which makes the red blood cells likely to distort into a sickle shape.

side chain Part of an amino acid that provides its unique quali- ties; also referred to as the R group.

simple carbohydrates Carbohydrates that consist of one sugar unit (monosaccharides) or two sugar units (disaccharides).

skinfold caliper Tool used to measure the thickness of subcu- taneous fat.

small for gestational age (SGA) Term for babies who weigh less than the 10th percentile of weight for gestational age.

small intestine Long coiled chamber that is the major site of food digestion and nutrient absorption.

social drinking Moderate drinking of alcoholic beverages in social settings within safe limits.

sodium (Na+ ) Major cation in the extracellular fluid.

sodium-potassium pump Protein located in the cell membrane that actively transports sodium ions out of the cell and potassium ions into the cell.

solanine Toxin found in potato surfaces exposed to light that can cause fever, diarrhea, and shock if consumed in large amounts.

solid foods Foods other than breast milk or formula given to an infant, usually around 4–6 months of age.

solubility Ability to dissolve into another substance.

soluble fiber Type of fiber that dissolves in water and is fer- mented by intestinal bacteria. Many soluble fibers are viscous and have thickening properties.

solvent Liquid in which substances dissolve to form a new solu- tion. Water is called the universal solvent because it can dissolve a variety of substances, including minerals and glucose.

specific heat Measurement of the energy required to raise a gram of a substance, such as water, 1 degree Celsius.

sphincters Circular rings of muscle that open and close in response to nerve input.

spina bifida Serious birth defect in which a portion of the spinal cord and its protective membranes (meninges) protrude from the vertebral column.

spores Hardy reproductive structures that are produced by cer- tain bacteria and fungi.

sports anemia Low concentrations of hemoglobin in the blood; results from an increase in blood volume during strenuous exercise.

starch Storage form of glucose in plants.

sterols Category of lipids that contains four connecting rings of carbon and hydrogen. Cholesterol is the most common sterol.

stomach J-shaped muscular organ that mixes and churns food with digestive juices and acid to form chyme.

stomatitis Inflammation of the mucous lining of the mouth.

stool Waste produced in the large intestine; also called feces.

stroke volume Amount of blood pumped by the heart with each heartbeat.

stroke Interruption or cessation of circulation to a region of the brain that deprives the area of oxygen and nutrients and can result in paralysis and possibly death.

subcutaneous fat Fat located under the skin and between the muscles.

substrate Substance or compound that is altered by an enzyme.

sucrose Disaccharide composed of glucose and fructose; also known as table sugar.

sudden infant death syndrome (SIDS) Unexplained death of an infant at less than 1 year of age.

sugar alcohols Type of sweetener often used in sugar-free foods. Includes xylitol, mannitol, and sorbitol. Also known as polyols.

sugar substitutes Alternatives to table sugar that sweeten foods for fewer kilocalories.

sulfate (SO4) Oxidized form of the mineral sulfur.

sulfites Preservatives used to help prevent foods from turning brown and to inhibit the growth of microbes; often used in wine and dried fruit products.

sustainable Referring to a method of resource use that can be maintained indefinitely because it does not deplete or permanently damage the resource.

Glossary G-19

systolic pressure Top number in a blood pressure reading that measures the pressure in the arteries when the heart muscle contracts.

T target heart rate Heart rate in beats per minute (expressed as a percentage of maximum heart rate) achieved during exercise that indicates the level of intensity at which fitness levels can increase.

tertiary structure Protein structure that occurs when the side chains of the amino acids, most often containing sulfur, form bonds resulting in loops, bends, and folds in the molecule.

thermic effect of exercise (TEE) Increase in muscle contrac- tion that occurs during physical activity, which produces heat and contributes to the total daily energy expenditure.

thermic effect of food (TEF) Amount of energy expended by the body to digest, absorb, transport, metabolize, and store energy-yielding nutrients from foods.

thermogenesis Generation of heat from the basal metabolism, digestion of food, and all forms of physical activity.

thiamin pyrophosphate (TPP) Coenzyme form of thiamin with two phosphate groups as part of the molecule.

thirst mechanism Complex interaction between the brain and the hypothalamus triggered by a depletion of body water; the interaction leads to a feeling of thirst.

thyroxine Less active form of thyroid hormone; also known as tetraiodothyronine (T4)

thyroxine-releasing hormone (TRH) Hormone secreted by the hypothalamus that stimulates the pituitary gland to release thyroxine-stimulating hormone (TSH).

thyroxine-stimulating hormone (TSH) Hormone released by the pituitary that stimulates the thyroid gland to trap more iodine to produce more thyroid hormone (T4 and T3).

toddlers Children 1 or 2 years old.

Tolerable Upper Intake Level (UL) Maximum daily amount of a nutrient considered safe in a group of similar individuals.

tongue-thrust reflex Forceful protrusion of the tongue in response to an oral stimulus, such as a spoon.

total daily energy expenditure (TDEE) Total kilocalories needed to meet daily energy requirements.

total iron-binding capacity (TIBC) Blood test that measures the amount of iron that transferrin can bind; a higher TIBC indi- cates iron-deficiency anemia.

toxicity Level of nutrient intake at which exposure to a substance becomes harmful.

toxin Poison that can be produced by living organisms.

trabecular bone Inner structure of bone, also known as spongy bone because of its appearance. This portion of bone is often lost in osteoporosis.

trace minerals Minerals needed in amounts less than 20  milligrams daily. These include iron, zinc, selenium, fluoride, chromium, copper, manganese, and molybdenum.

trans fats An unsaturated fatty acid formed as the result of hydrogenation. This type of fatty acid causes a reconfiguring of some of its double bonds. A small amount of trans fats occur naturally in foods from animal sources.

trans Configuration of a fatty acid in which the carbon atoms are on opposite sides of the double bond.

transamination Transfer of an amino group from one amino acid to a keto acid to form a new nonessential amino acid.

transcription First stage in protein synthesis, in which the DNA sequence is copied from the gene and transferred to messenger RNA.

transfer RNA (tRNA) Type of RNA that transfers a specific amino acid to a growing polypeptide chain in the ribosomes dur- ing protein synthesis.

transferrin Iron-transporting protein.

translation Second phase of protein synthesis; the process of converting the information in mRNA to an amino acid sequence in the ribosomes.

transport proteins Proteins that carry other substances, mainly nutrients, through the blood to various organs and tissues. Pro- teins can also act as channels through which some substances enter your cells.

traveler’s diarrhea Common pathogen-induced intestinal disor- der experienced by some travelers who visit areas with unsanitary conditions.

tricarboxylic acid (TCA) cycle Cycle of aerobic chemical reactions in the mitochondria that oxidize glucose, amino acids, and fatty acids, producing hydrogen ions to be used in the elec- tron transport chain, some ATP, and by-products carbon dioxide and water.

triglycerides Type of lipid commonly found in foods and the body; also known as fat. Triglycerides consist of three fatty acids attached to a glycerol backbone.

tripeptide Chain of three amino acids joined together by peptide bonds.

trivalent chromium Oxidized form of chromium (Cr+3) found in food.

type 1 diabetes Autoimmune form of diabetes in which the pan- creas does not produce insulin.

type 2 diabetes Form of diabetes characterized by insulin resistance.

Type I osteoporosis Form of osteoporosis that results from reduced estrogen levels and is characterized by rapid loss of bone mass.

Type II osteoporosis Form of osteoporosis that results from aging and is characterized by the slow loss of bone mass over time.

G-20 Glossary

U ulcer Sore or erosion of the stomach or intestinal lining.

ulcerative colitis Chronic inflammation of the colon that results in ulcers forming in the lining.

umbilical cord Cord connecting the fetus to the placenta.

undernourished Characterized by an inadequate energy intake or a deficiency in quality or quantity of one or more individual nutrients.

underweight Weighing too little for your height; defined as a BMI less than 18.5.

unintentional food additives Substances that enter into foods unintentionally during manufacturing or processing.

United States Pharmacopeial Convention (USP) Non- profit organization that sets quality standards for dietary supplements.

unsaturated fatty acid Fatty acid in which there are one or more double bonds between carbons.

upper esophageal sphincter Muscular ring located at the top of the esophagus.

urea Nitrogen-containing waste product of protein metabolism that is mainly excreted through the urine via the kidneys.

V vary Diet principle of consuming a mixture of different food groups and foods within each group.

vegetarian Person who avoids eating animal foods. Some veg- etarians only avoid meat, fish, and poultry, while others (vegans) avoid all animal products, including eggs and dairy.

very low-density lipoproteins (VLDLs) Lipoproteins that deliver fat made in the liver to the tissues. VLDL remnants are converted into LDLs.

villi Small, fingerlike projections that line the lumen of the small intestine.

virus Microscopic organism that carries genetic information for its own replication; can infect a host and cause illness.

visceral fat Body fat associated with the internal organs and stored in the abdominal area.

vitamins Thirteen essential, organic micronutrients that are needed by the body for normal functions.

VO2 max Maximum amount of oxygen (ml) a person uses in 1 minute per kilogram of body weight.

W waist circumference Measurement taken at the top of the iliac crest or hip bone; used to determine the pattern of obesity.

wasting Diminishment of muscle and fat tissue caused by extremely low energy intake.

water balance State of equilibrium when the intake of water equals the amount of water excreted.

water intoxication Potentially dangerous medical condition that results from drinking too much water too quickly, also known as hyperhydration; can lead to hyponatremia and pos- sible death.

water-soluble vitamins Vitamins that dissolve in water; they generally cannot be stored in the body and must be consumed daily.

weight management Maintaining a healthy body weight; defined as having a BMI of 18.5–24.9.

Wernicke-Korsakoff syndrome Severe brain disorder asso- ciated with chronic excessive alcohol consumption; symptoms include vision changes, loss of muscle coordination, and loss of memory; the cause is a thiamin deficiency.

whole grains Grain foods that are made with the entire edible grain kernel: the bran, the endosperm, and the germ.

Wilson’s disease Rare genetic disorder that results in accumula- tion of copper in the body.

working poor Individuals or families who are steadily employed but still experience poverty due to low wages or high dependent expenses.

X xerophthalmia Permanent damage to the cornea causing blind- ness; due to a prolonged vitamin A deficiency.

Z zoochemicals Non-nutritive animal compounds that play a role in fighting chronic diseases.

zygote Fertilized egg prior to the first cleavage (which occurs at approximately 72 hours).

I-1

Note: The letters fig indicate a figure on the page. The letter t indicates a table.

A ABCD method of assessing nutritional status,

19–21, 20t, 33 absorption. See also digestion; metabolism; small

intestine active transport, 93 alcohol, 252–253fig, 260–261fig, 263,

273fig–274 biotin, 374–375 calcium, 446fig, 462fig carbohydrates, 120–122, 121fig circular folds, 80fig copper, 479 defined, 76 endocytosis, 93 facilitated diffusion, 93 fat-soluble vitamins, 321fig fluids, 93 gastric juices and, 89 GI tract, 77fig iron, 387, 473t–474fig lipids, 165–171, 166fig, 169fig, 198–199 malabsorption, 19. See also celiac disease metabolic changes, 300–302, 301fig, 305t, 312 monosaccharides, 122fig nutrient, 90, 92fig–93 proteins, 211–213, 212fig reabsorption, sodium, 414–415fig, 420 sodium, 438–439 sodium-potassium pump, 413 vitamin A, 330, 352 vitamin B12, 384fig–385 vitamin C, 387 vitamin D, 342, 352 vitamin E, 342 vitamin K, 345 vitamins, 320–321fig, 351fig water-soluble vitamins, 321fig, 360fig zinc, 481fig

absorptive state, 300, 305t, 312 Acceptable Macronutrient Distribution Range

(AMDR). See also Dietary Reference Intakes (DRIs)

energy, related to, 46fig defined, 47 calculating, 48 dos and don’ts, 48t dietary fat, 175–176, 199, 595, 707 carbohydrates, 129, 150, 549 older adults, recommendations, 707 protein, 224, 241 young children, recommendations, 668

acceptable tolerance levels, 758

accessory organs, digestion and absorption, 84, 105fig

carbohydrate, 121fig lipid, 166fig protein, 212fig

acesulfame-K, 140t acetaldehyde dehydrogenase (ALDH), 253,

273, 306 acetaldehyde, 253 acetyl CoA

alcohol metabolism and, 306fig from amino acids, 288fig, 295 from fatty acids, 287, 294fig–295 ketogenesis and, 304fig metabolic process summary, 299t overview of metabolism, 298fig oxidation, 295–296fig pantothenic acid and, 373fig pyruvate converted to, 290, 293fig TCA cycle, 296fig thiamin and, 365

acid-base balance, role of water, 409 acidity. See pH acid reflux, 98 acidosis, 219 acne, 332fig, 684 active transport, 92fig, 93, 106fig activity. See exercise acute, 19 acute dehydration, 607 adaptive thermogenesis, 513 added sugars, 22, 135fig–136

beverages, 137t–139 fitting in balanced diet, 54fig, 54t food label information, 60fig limiting kilocalories, 50 Nutrition Facts panel, 60fig in young children’s diets, 671

adenosine diphosphate (ADP), 286fig, 311 adenosine triphosphate. See ATP (adenosine

triphosphate) Adequate Intake (AI), 45, 46fig, 47, 48t adipocytes, 120, 172fig, 542–543fig. See also

fat cells adiponectin, 546 adipose tissue. See also fat, body

body fat storage, 519–520fig fat, use of, 593 fat cells and, 544 fatty acid and glycerol, 592fig energy balance and, 508 triglycerides stored in, 173

adolescents. See also children nutritional needs, overview, 682fig–684,

690fig pregnant, 638–639 social and emotional changes, 684–685, 690

adrenaline. See epinephrine adults. See also older adults

obesity trends, 23fig young, college binge drinking, 270fig

advertising alcohol, 251fig childhood obesity and, 681 food choices and, 6

aerobic energy production, 587–588 aerobic exercise, 558–560 aerobic metabolism, 282, 283 aerophagia, 98 age. See also adolescents; children; infants; older

adults basal metabolism and, 512t and thermic effect of food, 513t

age-related macular degeneration (AMD), 323fig

prevention, 710t, 714 zinc and, 482

aging. See also older adults bone mass changes, 456fig changes in function, 700–701 decreased mobility, 712–713 demographics, 698–700, 699fig, 723fig effects on nutrition, 723fig and hypertension, 718–720 and increased supplement use, 348

agriculture challenges, and food shortages, 785–786 community-supported, 764 efforts to reduce malnutrition, 797 farmers markets, 765 farm-to-table continuum, 747fig genetic engineering (GE), 766–769t, 767fig hormones and antibiotics in livestock,

755–576 improving, 791–792 organic, 759–760fig pesticide use, 757–759, 758fig

air-displacement plethysmography, 521–522t albumin, 218–219 alcohol

absorption, circulation, and metabolism, 252–256, 253fig, 273

abuse and alcoholism, 270–271, 717–718 alcohol poisoning, 257–258 alcohol tolerance, 254 alcohol use disorder (AUD), 269–272, 275 amount in standard drink, 251–252fig bar foods and, 261fig cancer and, 268 cardiovascular disease and, 265, 266fig content in beverages, 250t defined, 248 dehydration, 420, 427 depression and, 264–265

Index

I-2 Index

alcohol (cont.) exercise and, 606 factors affecting metabolism, 255–256 forms of, 248–249 hangovers, 258–259, 274 hormone interaction, 263 hypertension and, 720 impact on bone mass, 459 injuries caused by, 258 kilocalories in selected drinks, 262fig limiting, 50 liver disease and, 263–264 long-term excessive consumption, 259–265,

268–269, 271–272t, 274 metabolism, 305–307, 306fig, 312 moderate consumption, 195, 266–267 pregnancy and, 268fig–269, 626 progressive effects, 272t providing kilocalories, 10fig reasons for drinking, 250–251, 272 role in energy metabolism, 298t short-term effects, 256–259 structure, 248fig and thermic effect of food, 513t underage drinking, 270 use in older adults, 717–718

alcohol dehydrogenase (ADH), 253, 273, 306 alcoholic hepatitis, 263–264 alcoholic liver disease, 263–264fig aldosterone, 414–415 alkalosis, 219 allergen, 220, 221 allergies. See food allergies alpha end, 158 alpha-ketoglutarate, 295 alpha-linolenic acid, 161, 173fig–174, 182fig alpha-tocopherol (α-tocopherol), 342, 343fig Alzheimer’s disease, 710t, 714–715 amenorrhea, 603 American diet, overview, 22–24, 33 amine group, 207 amino acids

amino acid pools, 213–214fig, 240fig amino acid score, 225t–226, 241 amino acid synthesis, DNA and, 379–380 absorption, 211 anatomy, 207fig converted to acetyl CoA, 295 deamination, 216–217fig essential and nonessential, 207, 208t, 240 glucogenic, 220, 221, 291–292fig, 292t ketogenic, 287, 292fig metabolized, 213–217, 214fig as protein building blocks, 206–208 from proteins, 13 protein synthesis, 214–216, 215fig to pyruvate, 290–293 role in energy metabolism, 298t sodium as transport, 439fig stored as triglycerides, 302 sulfate in, 454fig supplements, 231, 610 vitamin B6, and, 376 See also essential amino acids; nonessential

amino acids amylopectin, 117fig amylose, 117fig anabolic reaction. See also absorptive state

defined, 218

catabolic and, 282fig–283, 311 hormonal regulation, 285t metabolic pathways, 299t

anaerobic energy production, 586–587fig anaerobic exercise, 558–559 anaerobic metabolism, 282, 283 anaphylaxis, 653 android obesity. See central obesity anemia, 478

hyperphenylalanemia, 308 microcytic hypochromic, 378 nutrient-deficient, 495–496, 501 pernicious, 385, 497 prevention, 710t sickle cell, 216 sports, 601

anencephaly, 380 angiotensin II, 414 Animal and Plant Health Inspection Service

(APHIS), 748t anions, 411 anorexia nervosa, 528t–529 anthocyanins, as functional food, 16t anthropometric assessments, 20–21 anthropometric data, 20–21 antibiotic-resistant, 756 antibiotics, use in livestock, 756 antibodies, 220–221 anticoagulant, vitamin E as, 343–344 antidiuretic hormone (ADH), 414 antimicrobials, 757 antioxidants, 322–324, 323fig

carotenoids as, 332 defined, 322 increasing intake, 194 role in exercise, 599, 601 structure/function claim, 63fig vitamin E as, 342–343 vitamins supporting, 319t

anus, 83 A1C test, interpreting, 144t apoptosis, 393 appetite

eating trigger, 540 appetite control, role of proteins, 221 environmental factors and, 547 older adults, 703–704, 708–709 in pregnancy, 635 sugar-sweetened beverages, impact on, 138 suppressing, 566–567

arachidonic acid, 173fig–174 ariboflavinosis, 368, 369fig arsenic, 494 arterial injury, 191fig. See also cardiovascular disease artery, 191fig. See also blood vessels arthritis, 713 ascorbic acid, 387fig aspartame, 140t–141 atherosclerosis, 190–191fig athletes, and thermic effect of food, 513t ATP (adenosine triphosphate)

active transport and, 93 energy production, 214fig, 240fig, cells as energy source, 285–286 defined, 282–283 from electron transport chain and oxidative

phosphorylation, 296–297 exercise and, 586fig–587fig fermentation, 248fig

glycolysis, 287–288fig, 289fig produced by macronutrients, 287–299, 288fig role in metabolism, 285–287, 286fig, 311

atrophic gastritis, 383–384 atrophy, 585 attention-deficit/hyperactivity disorder (ADHD),

668–669

B B vitamins. See also specific vitamin names

as coenzymes, 361 function in energy metabolism, 362fig

babies. See infants bacteria. See also foodborne illnesses; specific

bacteria names beneficial, 15, 83t causing foodborne illness, 733t–734t E. coli, 735 GI flora, 81–82 infant protection, 642, 647 intestinal, effect on diet, 556 leaky gut syndrome and, 91 salmonella, 99, 735 types, 735

balanced diet, 15–16, 32. See also healthy eating; MyPlate

defined, 40 diabetic, 146–147 mixing up food group choices, 52fig phytochemical color guide, 324t

bariatric surgery, 566 basal metabolism, 511

basal metabolic rate (BMR), 511 factors affecting, 512t

beer, 250t, 266 behavior modification, weight management,

560–561, 570 belching, 98 beriberi, 366 beta end, 158 beta-carotene

absorption, 330 as functional food, 16t genetically engineered, 767–768 older adults, needs for, 704t, 707–708, 714 phytochemical color guide, 322t supplements, overconsuming, 334 vitamin A and, 328–330, 329fig, 333, 352

beta-glucan, as functional food, 16t beta-oxidation, 294fig, 297fig, 299t beverages. See also alcohol; fluid balance; water

added sugar, 136-139, 137t alcoholic. See alcohol body water, source of, 410, 416 bottled water, 417–418 caffeinated, 420 energy in, 508–510 healthier, shifting to, 50–51 sugar-free, 136fig

bicarbonate ions, 89–90t bicarbonate loading, 610 bile. See also gallbladder

cholesterol in, 174 digestive juices, 84fig digestive system and, 77fig fat-soluble vitamins and, 321 gallbladder disease and, 99 pH scale, 88fig

Index I-3

purpose, 89, 90t, 105 role in emulsifying fat, 168fig

binders, 435 binge drinking, 251, 270fig binge eating disorder (BED), 528t, 529 bioaccumulation of toxins, 737fig bioavailability

vitamins, differences in, 320–321, 351 calcium, 446fig copper, 479 iron, 473–474 minerals, 434–435, 436t trace minerals, 470 zinc, 482

biochemical nutrition assessment, 21 biodiversity

and genetic engineering, 767 sustainable food system, 763

bioelectrical impedance (BIA), 522t–523 biotechnology, genetic engineering, 766, 771fig biotin

daily needs, 375 food sources, 375 metabolic functions, 374–375fig overview, 374, 399fig sources and functions, 363t toxicity and deficiency, 375

blackout, 257 bleaching, 330 blindness, 335 blood

alcohol circulation, 254 calcium regulation, 446, 447fig iron needs, 683 vitamin D and calcium, 338fig

blood alcohol concentration (BAC), 254–255t, 272t, 273

blood clotting vitamin E and, 344 vitamin K and, 345fig–346fig vitamins supporting, 319t

blood glucose. See also diabetes; sugar exercise and, 147 glycemic index, 133–134 interpreting levels, 144t maintaining levels, 124–127, 125fig, 149fig proteins and, 220

blood lipid profile, 192 blood pressure. See also hypertension

alcohol consumption, moderate, 266 calcium intake, 448 classification, 719t gestational hypertension, 638 heart disease, risk factor, 192 managing, 720t normal, 192 potassium and, 444 vegetarian diet and, 236 vitamin D and, 337 water and sodium effects, 414–415fig, 427fig

blood vessels. See atherosclerosis; cardiovascular disease; heart disease

body composition. See also body fat; percent body fat

assessing, 519–523 and cardiorespiratory exercise, 580–581 indirect assessments, 521–523 overview, 532 and physical fitness, 580t

standards for men and women, 520t water composition, 406fig, 426fig

body fat. See fat, body body image, distorted, 528–529 body mass index (BMI)

as anthropometric data, 20–21 converting to percent body fat, 526 health risk and, 526fig and healthy weight, 524–526, 525fig overview, 533fig

body size, basal metabolism and, 512t body weight. See obesity; overweight; under-

weight; weight; weight management bolus, 78 bomb calorimeter, 508, 510fig bone health. See also osteoporosis

in athletes, 603–604 calcium and, 446 changes in mass, 456fig decline in older adults, 701fig development in adolescents, 682–683 measuring mass density, 456–457fig mineralization, 436 normal and abnormal, 450fig and physical fitness, 581t potassium and, 444 vitamin A and, 332 vitamin D and, 336–337 vitamin K and, 346 vitamins supporting, 319t

bone matrix, 346fig bone mineral density (BMD), 455–459 bones, cortical and trabecular, 446, 448fig boron, 494 botanicals, and pregnancy, 267 bottled water, 417–419, 418t botulism, 651 bovine growth hormone (BGH), 755–756 brain

alcohol effects, 256–258, 257fig, 272t, 274fig Alzheimer’s disease, 714–715 basal metabolism, 511 brain damage, undernutrition and,

794–795 breastfeeding and brain development, 643 folic acid and, 625 hunger and satiety, 541–543, 542fig iron and, 475, 491 Menkes’ disease, 480 neural tube development, 380 older adults, changes in, 702 PKU and, 308 prions, 736 Wilson’s disease, 480

bran, 131 breakfast. See also Table Tips

children’s, 676–677 carbohydrate-loading, 592t food plan, 55fig saturated fat, 186t School Breakfast Program, 790t

breastfeeding and breast milk benefits, 640–649, 656 kilocalories and fat content, 642 Kwashiorkor and, 234–235 similarity to infant formula, 467 solid foods and, 651 substances to avoid while, 644, 646 vitamin D and, 349

women at risk for malnutrition, 788, 796 at work, 645

brown adipose tissue (BAT), 519–520fig buffers, 219 bulimia nervosa, 528t, 529 burping, 98

C caffeine

basal metabolism and, 512t as ergogenic aid, 609–610 exercise and, 606 limiting intake, 50 pregnancy and, 626fig water and, 420, 427

calciferol, 335 calcification, 452 calcitonin, 446 calcitriol, 336 calcium

adolescents’ needs, 682–683 bioavailability and absorption, 446fig blood, vitamin D and, 338fig daily needs, 448 DASH diet, 441, 719–720 deficiency in athletes, 602 estimating intake, 458 food sources, 448–449fig functions, needs, sources, toxicity, and defi-

ciency, 437t homeostasis, 447fig hormones and, 446 metabolic functions, 446, 448 need in older adults, 704t, 708–709 needs in young children, 668, 670 percent absorption, 462fig selenium sources, 485fig supplements, 449–450 toxicity and deficiency, 449 vegan diet and, 237

Calculation Corner Acceptable Macronutrient Distribution

Range (AMDR), 48 adolescents’ calcium needs, 683 amino acid score, 226 blood alcohol concentration, 255 body volume and density, 521 calculating AMDR for fat, 175–176 converting BMI to percent body fat, 526 converting IUs for vitamin A, 333 converting IUs for vitamin D, 338 converting IUs for vitamin E, 343 daily carbohydrate intake, 129 dietary folate equivalents (DFE), 380 energy content of meal, 510 energy density, 553–554 fluid needs for distance runners, 608 growth chart, 667fig Harris-Benedict equation, energy

expenditure, 705 kilocalorie and fat content of breast milk, 642 kilocalories in chips and soda, 11 niacin equivalents, 371 nitrogen balance, 221–222 percentage weight loss, 552 protein digestibility corrected amino acid

score (PDCAAS), 226–227 protein requirements, 224 target heart rate, 583

I-4 Index

calories, 10. See also kilocalorie food label information, 60fig Nutrition Facts panel, 60fig

Campylobacter jejuni, 733t, 734 cancer

alcohol and, 268 carcinoma, 392t protein overconsumption, 234 vegetarian diet, 236 cause of death, 17t colon, 104, 148 effects of soy, 228 esophageal, 98 fiber and, 128–129 folate and, 380 metastasis, 393 physical fitness benefits, 580t prevention, 710t risk reduction, 392–396, 395t, 400fig, 580t supplements and, 348

canning, 749 capillaries, 218 carbohydrates

carbohydrate loading, 590–592t, 591t carbohydrate metabolism, vitamin B6, and,

376–377 carbohydrate-based fat substitutes, 188t change in blood glucose, 126fig chemical composition, 9fig, 31fig classifications, 112–119, 147, 148fig digestion and absorption, 120–122, 121fig exchange system, 55–58 functions, 122–123 high-intensity exercise and, 588–592 in second and third trimesters, 635–636 metabolism during feeding and fasting, 305t needs in young children, 668 for older adults, 704t, 707 packaged foods, 132–133 primary role, 12t–13, 32 recommended intake and sources,

129–134, 130fig stored as glycogen, 300 stored as triglycerides, 302 structure, 206fig timing intake with exercise, 597t–599 use during exercise, 586–596, 594fig weight management and, 549–550

carboxylation, 346fig carcinogen, 393 carcinogenesis, 393fig carcinoma, 392t cardiac arrhythmia, 265 cardiac myopathy, 265 cardiorespiratory conditioning, 581 cardiorespiratory endurance, 578 cardiorespiratory exercise, 580–581 cardiovascular disease (CVD)

alcohol and, 265, 266fig defined, 190 physical fitness and, 580t trans fats and, 187 fiber and, 127–128 metabolic syndrome and, 142 risk factors, 192 supplements and, 348

cardiovascular system, nutrient distribution, 96fig–97, 107fig

carnitine, 392

carotenoids antioxidants, 322, 324, 332 breast milk, 641 dietary fat and, 173 overconsumption, 334 provitamin-A, 328 vitamin A and, 333–334

cartenodermia, 334fig cascade, 345 catabolic, 218 catabolic reaction, 282fig–283, 311 cataracts, 322, 323fig cataracts, prevention, 710t, 714 cations, 411 cecum, 81 celiac disease, 99–101, 100fig, 107fig cell differentiation, vitamin A and, 330 cell division, vitamin A and, 330 cell membrane

intestinal permeability, 91–93 maintenance, 173fig–174 metabolism within, 283fig role of phospholipids and cholesterol,

174fig–175, 199fig vitamin E as antioxidant, 343fig, 352fig water balance and, 411–413

cells ATP as energy source, 285–286 mast, 652 metabolic processes, 299t metabolism within, 283fig normal, micronutrient roles in, 394fig regulation by vitamin D, 337 vitamin E as antioxidant in membranes, 343 water and, 408

cellulose, in plant cell, 118fig Centers for Disease Control and Prevention

cold recommendations, 390–391 dental hygiene, 671 food deserts, 782–783 food safety while traveling, 746 growth chart, 667 hand cleaning, 742 food protection responsibilities, 748t water safety, 792

central obesity, 520–521fig cerebellum, effects of alcohol, 257fig, 274fig cerebral cortex, effects of alcohol, 257fig, 274fig certified diabetes educator (CDE), 145 ceruloplasmin, 479fig cheilosis, 368, 369fig chemical agents, foodborne illness and, 738–739 chemical digestion, 76, 77fig, 86–90 chemical messengers, protein as, 218 chemical structures

alcohol, 248fig alpha-tocopherol, 343fig amino acids, 207fig ATP to ADP, 286 ATP, 586fig biotin, 375fig cellulose, 118fig disaccharides, 114fig enzyme in action, 87fig fatty acids, 158fig, 159fig, 160fig, 161fig, 163fig folate and coenzyme form, 379fig forms of vitamin B6, 376fig fructose, 113fig galactose, 113fig–114fig

glucose, 112fig–113fig iron-containing hemoglobin and myoglobin,

475fig lipids, 198fig maltose, 114fig micronutrients, 206fig monosaccharide, 114fig oligosaccharide, 116fig pantothenic acid and coenzyme A, 373fig phospholipid, 164fig proteins, 209fig sterol, 165fig sulfate, 454fig triglycerides, 163fig vitamin B1, 365fig vitamin B2, 367fig vitamin B3, 370fig vitamin D, 336fig, 337fig vitamin K, 345fig

chemistry metabolism overview, 282–283 protein as chemical messengers, 218 vitamin vs. mineral, 434fig water as universal solvent, 407fig

Chemistry Boost ATP, 586fig carboxylation, 346fig chemical bonds, 9 condensation reaction, 114 covalent bonds, 11 fatty acid notations, 162 fermentation, 249fig hydrolysis, 86 oxidation and iron reduction, 475 myoglobin, and oxygen transport, 474–475 oxidation-reduction reactions, 284fig pH scale, 88 vitamin B2 in redox reactions, 368fig water and acid-base balance, 409

chief cells, 79 Child and Adult Care Food Program, 790t childhood obesity

breastfeeding and, 643 health effects, 687–688 increase in, 679t overview, 690 reasons, 678–682

children. See also adolescents; infants at risk for malnutrition, 788–789 eating habits, overview, 689 effects of undernutrition, 794–795fig, 795t factors affecting nutrition, 673–678 iron poisoning in, 477 rickets in, 339–340fig school lunches, 675–676t, 790t vitamin D needs, 349

children, young food preferences, 671–673 nutrient-dense needs, 689 nutritional needs, 666–671

Chlamydia pneumoniae, 190 chloride, 461fig

daily needs and sources, 443 functions, needs, sources, toxicity, and

deficiency, 437t metabolic functions, 442

chlorophyll, 112 cholecalciferol (vitamin D3), 335–336fig cholecystokinin (CCK, 94t–95fig, 542fig

Index I-5

cholesterol. See also fat, dietary; lipids; lipoproteins alcohol consumption, 266 blood concentrations, 192t body fat and, 520 cell membranes, role in, 174fig–175 childhood obesity and, 687, 690 defined, 165 dietary guidelines, 50 fiber and, 128fig food label content claims, 63t “good” and “bad,” 169–171fig, 184–185 heart disease risk factor, 190–195, 192t hormones, bile, and vitamin D, 174 limiting, 50 nonessential, 177–178 Nutrition Facts panel, 60fig, 69fig, 133fig recommended daily intake, 175–178 soy protein and, 228 in specific foods, 178t structure, 165fig

choline, 164, 391 choline, 391 ChooseMyPlate.gov, tips for children’s nutrition,

674fig–675fig chromium

daily needs, functions, and sources, 471t, 488–489fig

metabolism, 488 overview, 500 toxicity and deficiency, 471t

chronic dehydration, 607–608 chronic disease, 16–17, 18fig, 32. See also specific

disease names genetic and environmental factors, 18fig pre-pregnancy management, 627 and risk for malnutrition, 789, 796

chronologic age, 701 chylomicrons, 167–168fig, 171fig chyme, 79 cigarettes. See smoking ciguatera poisoning, 737 circular folds, 80fig cirrhosis, 264fig cis, 162–163fig citric acid cycle. See tricarboxylic acid

(TCA) cycle climate change, factor in food shortages, 786 closed dating, 751fig Clostridium botulinum, 732, 733t Clostridium perfringens, 733t, 734 clotting factors, 345 coagulation, 345 cobalamin, 382 coenzymes

A, pantothenic acid and, 373fig biotin in energy metabolism, 375fig defined, 13, 360 form, and water-soluble vitamins, 361,

362t–363t metabolism regulation, 284 pyruvate and, 288, 293–294 TCA cycle and, 295–296fig

cofactors, 436, 470, 472 collagen, 387, 388fig colon, 81. See also large intestine

iron absorption and transport, 474fig selenium metabolism, 484fig zinc absorption, 481fig

colon cancer, 104

colostrum, 641 common bile duct, 84fig common cold, vitamin C and, 390–391 community organizations, efforts to reduce

malnutrition, 797 community resources, older adults, 717 community-supported agriculture, 764 complete protein, 227, 229 complex carbohydrates, 113 conception, 620 condensation, 113–114fig condensation reaction, 208fig, 408 conditionally essential amino acids, 208, 240 conditioning, 582. See also exercise; physical

fitness effects on glucose and glycogen, 589 effects on use of fat, 593

cones, 330 congeners, 259 congenital hypothyroidism. See cretinism Congregate Meals for the Elderly, 790t congregate meals, 717 consensus, 24–25fig constipation, 102

beneficial bacteria, 83t during pregnancy, 636 fiber and, 127 prevention, 710t

control group, 26 convenience, food choices and, 6–7 cooking, vitamins destroyed during, 325 cooking temperature, 743–744fig, 744t copper

absorption and transport, 479 daily needs, 480fig functions, needs, and sources, 471t intake during pregnancy, 631 metabolic functions, 479 overview, 499 sources, 480fig toxicity and deficiency, 471t, 480

Cori cycle, 291fig coronary heart disease. See heart disease cortical bone, 446, 448fig cortisol, 126, 285t cost, food choices and, 6–7 cravings, during pregnancy, 633 C-reactive protein (CRP), 190 creatine monohydrate, 609 creatine phosphate (PCr), 286 cretinism, 491 critical periods, 621 Crohn’s disease, 104 cross-breeding, vs. genetic engineering, 766–767fig cross-contamination, 742–743fig Cryptosporidium parvum, 734t crypts, 81 culture, food choices and, 5 cupric copper, 479 cuprous copper, 479 cyanocobalamin, 383fig cysteine, 454fig cytochromes, 297 cytosol, 283fig

D daily values. See Nutrition Facts panel; food label

information; percent Daily Values (%DVs)

dairy calcium content, 449fig carbohydrate sources, 130fig, 132 copper sources, 480fig energy density, 565fig intake during pregnancy, 630fig iodine sources, 491fig kilocalorie needs, 53t magnesium content, 453fig manganese sources, 493fig nutrient-rich, 52fig older adults, needs for, 703fig phosphorus content, 451fig potassium sources, 445fig protein and saturated fat, 233fig protein sources, 229fig sodium content, 441fig vitamin A sources, 333fig vitamin B12 sources, 365fig vitamin B2 sources, 369fig vitamin D sources, 339fig vitamins in, 325fig, 352fig water content, 419fig zinc sources, 482fig

“danger zone,” 744–745fig DASH diet, 441, 719–720 deamination, 216–217fig, 297fig death

leading causes in US, 17t in malnourished children, 795t

deficiencies, 455 biotin, 375 calcium, 449, 602 chloride, 443 chromium, 488–489 copper, 480 fluoride, 487 folate, 381fig folate and vitamin B12, 496–497 iron, 477, 601 magnesium, 454 manganese, 493–494 molybdenum, 492 nutrient-deficient diseases, 17, 32, 495–497 pantothenic acid, 374 phosphorus, 452 potassium, 444–445 RED-S, 603fig–604 selenium, 485 sodium, 442 trace minerals, 471t, 472 vitamin B1, 365–366 vitamin B6, 378 vitamin B12, 385, 386 vitamin B2, 368–369fig vitamin C, 389fig water-soluble vitamins, 363t zinc, 483

dehydration, 607fig–608. See also fluid balance alcohol and, 420, 427 ECF and ICF depletion, 424 signs and symptoms, 421t

DeLaney Clause, 755 dementia

Alzheimer’s disease, 714–715 brain function, changes, 702 effect of coconut oil, 184

denature, 210fig dental caries, 136

I-6 Index

deoxyadenosylcobalamin, 383 depression

alcohol and, 264–265 childhood obesity and, 678, 687 disordered eating and, 529–530 older adults, 717

designated driver, 271 developed country, food insecurity in, 780 developing country, food insecurity, 784 DEXA scan. See dual-energy X-ray

absorptiometry (DEXA) diabetes. See also type 1 diabetes; type 2 diabetes

alcohol consumption and, 267 cause of death, 17t certified educator, 145 diagnosing, 144 exchange lists and, 55, 57–58 fiber and, 127–128 gestational, 146, 637 long-term damage, 146 prevention and control, 146–147 types and risk factors, 141–144, 143fig vegetarian diet and, 236–237

diabetes mellitus. See diabetes diarrhea

beneficial bacteria, 83t cause of death, 795t celiac disease and, 99–100 common intestinal disorders, 101 inflammatory bowel disease (IBD), 104 irritable bowel syndrome (IBS), 102 lactose intolerance and, 115 malnutrition, 234 traveler’s, 746 water balance, 411, 421

diastolic pressure, 102, 718 diet. See also balanced diet; healthy eating;

vegetarian diet; weight management; specific nutrient names

ADHD and, 669 average American, 22–24, 33 cancer risk and progression, 394–395 changes for older adults, 704t controlling portion sizes, 67t DASH, 441, 719–720 DRIs, 44–48 fad, 552 healthy eating principles, 40–44, 68 influencing health, 16–18 low FODMAP, 102 maintaining weight loss, 563 Mediterranean, 179–181 NEAT and, 516 role in bone mass, 457–458

dietary fiber. See fiber dietary folate equivalents (DFE), 380 Dietary Guidelines for Americans, 49. See also

MyPlate cancer prevention, 234 dietary cholesterol, 177 drinking alcohol, 251 milk intake, 340 older adults, recommendations,

709–710 overall recommendations, 50–51, 68 potassium intake, 444 sodium intake, 440 tools for healthy eating, 43t–44t

dietary intake, assessing, 19–20

Dietary Reference Intakes (DRIs), 43t–48, 44t, 48t, 68fig. See also Recommended Dietary

Allowance (RDA) dietary supplements. See supplements digestion. See also absorption; metabolism;

transport alcohol interfering with, 260–261, 263 carbohydrates, 120–122, 121fig chemical, 86–90 common disorders, 98–102, 104, 107 folate, 379fig gastric juices, 88–89 through GI tract, 84–85, 105fig lipids, 165–171, 166fig, 198 nutrient absorption, 90, 92fig–93 processes and organs, 76–84 proteins, 211–213, 212fig regulation by hormones and nervous system,

93–96 vitamins, 321fig–322, 351fig vitamins, water-soluble, 360fig

digestive disorders, common, 98–104 dinner. See also Table Tips

carbohydrate-loading, 592t food plan, 55fig saturated fat, 186t with and without alcohol, 261fig

dinucleotide phosphate (NADP+), 369–370fig dipeptide, 207 disability, factor in food insecurity, 783 disaccharides, 113–114, 116, 114fig discrimination, factor in malnutrition,

784–785 diseases. See also specific disease names

chronic, healthy diet and, 16–17, 18fig, 32

chronic, pre-pregnancy management, 627 illness as factor in food insecurity, 783 genetic metabolic disorders, 308–310, 313 nutrient-deficient, 17

disordered eating, 527–531 adolescents at risk, 685 and RED-S, 603

distillation, 250 distilled water, 418t diuretics, fluid balance and, 420, 427 diverticula, fiber and, 127 diverticulitis, 127, 710t diverticulosis, fiber and, 127fig DNA. See also genes

amino acid synthesis and, 379–380 fingerprinting, 748 zinc and, 481

docosahexaenoic acid (DHA), 173fig–174 double burden of malnutrition, 787 double-blind placebo-controlled study, 27 drugs. See also medications

basal metabolism and, 512t illicit, and pregnancy, 626

dual-energy X-ray absorptiometry (DEXA), 456–457fig, 522t–523

duodenum, 84fig

E E. coli, 732, 733t early-childhood caries, 647fig eating disorders, 527–531

diagnostic criteria, 528t

overview, 527–531, 533 warning signs, 530t

eclampsia, 638 ecosystem disruption, concerns in genetic

engineering, 768 edema, 219fig education, reducing malnutrition through, 793 eggs

Mediterranean diet, 179–180fig safe cooking temperatures, 744t source of protein, 187 vegetarian diet, 236

eicosanoids, 173fig–174 eicosapentaenoic acid (EPA), 173fig–174 electrolytes, 411

balance, minerals and, 436 exercise and, 604–605 during exercise, 422fig maintaining balance, 428fig

electron transport chain ATP from, 296–297fig, 312fig metabolic pathway, 288fig, 298fig, 299t

elimination, 76, 77fig elongation, 215fig, 216 embryo, 621 emergency kitchens, 791 emotions, food choices and, 7 emulsifier, 89, 165fig, 168fig endocytosis, 92fig, 93, 106fig endosperm, 131 endotoxins, 264 energy. See also metabolism

amino acid production, 214fig, 240fig calculating density, 553–554 from carbohydrates, 123, 149 DRIs related to, 46fig from fatty acids, 172–173 in food, 508–510 lower needs in older adults, 704–705 maintaining levels, 300 measuring expenditure, 517–519 production, 302–305 from proteins, 220t provided by nutrients, 8–9 storage, 300–302 sustainable food system, 763 energy-yielding nutrients, 8–9, 10fig

energy density, 40, 554fig–555fig energy expenditure, overview, 532 energy gap, 563 energy production, vitamins supporting, 319t energy balance

achieving, 519 factors involved, 514fig overview, 508–511, 532

energy bars, 231 enhanced water, 418t enriched grains, 132 enteric nervous system, 94–96 enterocytes, 81 enterogastrones, 94 enterohepatic circulation, 89 enterotoxigenic Escherichia coli environment. See also natural resources;

sustainable food system and body weight, 547–548, 550–551, 569 bottled water and, 418 food choices and, 5 impact of food production, 762t

Index I-7

Environmental Protection Agency (EPA) pesticide risks and regulation, 757–758fig responsibility of, 748t tap water regulation, 417 water supply safety, 493, 751–752

enzymes defined, 13 in digestion, 86–88, 87fig, 87t–88t, 105fig in protein digestion, 213t lack of, 308t–310, 309fig metabolic regulation, 284 mineral cofactors, 436 role of proteins, 220t

epidemiological research, 26 epigenetics, 18, 544–545 epigenome, 545fig epiglottis, 78fig epinephrine, 124, 285t epiphyseal plate, 682fig epithelial cells, healthy and vitamin A-deficient, 332fig epithelial tissues, vitamin A and, 330 ergocalciferol (vitamin D2), 335–336fig ergogenic aids, 609–611 Escherichia coli. See E. coli esophageal cancer, 98 esophageal problems, 98 esophagus, 77fig, 78 essential amino acids, 207, 208t, 223fig, 240.

See also amino acids essential fat, 519 essential fatty acids

best food sources of fat, 200 shape of, 162 function of, 173fig–174 recommended intake, 177

essential nutrients, 8 ester group, 328–329fig Estimated Average Requirement (EAR), 45, 46fig Estimated Energy Requirement (EER), 46fig,

47, 48t ethanol, 248, 273 ethnicity, effect on alcohol metabolism, 255–256 European corn borer caterpillar, 767fig Examining the Evidence

bottled water vs. tap water, 417–419 carbohydrates, 549–550 coconut oil, 183–185 diet and ADHD, 669 exercise and weight loss, 558–559 intestinal permeability, 91–92 kilocalorie restriction, effect on lifespan, 706 microbiome and obesity, 556–557 alcohol consumption, moderate, 266–267 NEAT, 516–517 probiotics, prebiotics, and synbiotics, 82–83 soy, effects on heart disease and cancer, 228 time of day to eat, 56–57 vitamin C, cold prevention, 390–391

exchange lists for healthy eating, 43t–44t exchange system, 55, 57–58, 69 excretion

excretory system, 97 sodium, 438–439 water, 410fig–411

exercise. See also conditioning; physical fitness cancer risk and, 393 cardiorespiratory, 580–581 childhood obesity and, 680–681 diabetics, 147

during pregnancy, 636t–637 effects of meals on, 596–599, 613 effects of vitamins and minerals, 613 energy out and, 511 energy sources, overview, 612 environmental factors and, 547 fluid intake and, 604–607fig, 606t, 613fig glucose and glycogen utilization, 588fig–590 hypertension and, 720 intense, and thermic effect of food, 513t intensity of, 558–560, 559fig, 582 kilocalories used, 557t lack of, 550–551 moderate and vigorous, 53t overexercise, 579 physical activity pyramid, 584fig reducing heart disease risk and, 195 role in bone mass, 458 water balance, maintaining, 422fig, 423 weight loss and, 555, 557, 563, 570

experimental group, 26 experiments, testing hypotheses, 26fig–27 extracellular fluid (ECF), 411fig, 424 eye, structure, 331fig. See also vision

F facilitated diffusion, 92fig, 93, 106fig fad diets, 552 failure to thrive (FTT), 648–649 family, impact on childhood obesity, 680 famine, 786 farming. See agriculture farm-to-table continuum, 747fig fasting, 302–305, 303fig, 305t fat-based substitutes, 188t–189 fat, body. See also obesity; weight management

excess alcohol stored as, 307 excess protein conversion, 217 health effects, 520–521 measuring methods, 522t stored in adipose tissue, 519–520fig

fat, dietary. See also lipids; oils; saturated fats aiding lipid absorption, 173 coconut oil, 183–185 fat substitutes, 188t–189 heart disease and, 193 moderate consumption, 199 percentage of kilocalories, 175–176 reduced-fat products, 189 sources, 181–182, 185–189 sterols and stanols, 187 unsaturated and essential fatty acids, 200 healthy, 555 meeting AMDR, 595, 707 timing intake with exercise, 597t–599 use during exercise, 586, 592fig–595,

594fig, 612 exchange system, 55–58 trans fats, 50, 61, 185–187, 193 food label content claims, 63t intake needs in young children, 668 servings for vegetarian diet, 238t

fat cells. See also adipocytes from amino acids, 214fig, 240fig formation and expansion, 543–544 overview, 569

fat-soluble vitamins functions, needs, and sources, 327t, 351

absorption and storage, 321fig, 351fig categorizing, 319fig defined, 14

fatty acids, 158–162, 158fig, 159fig, 160fig, 161fig role in energy metabolism, 298t converted to acetyl CoA, 294fig–295 double bond, 161–162 omega-3, 161, 182fig omega-6, 161 shape, 162 stability, 160 stored as triglycerides, 302 utilization during exercise, 592fig–593, 595

fatty liver, 263–264fig fatty streak, atherosclerosis, 191fig FDA. See Food and Drug Administration (FDA) fecal-to-oral transmission, 732 feces. See stool feeding state. See absorptive state ferment, 81 fermentation, 249fig, 272 ferric iron, 473 ferritin, 473 ferroportin, 473 ferrous iron, 473 fetal alcohol spectrum disorders (FASDs), 269 fetal alcohol syndrome (FAS), 268fig–269 fetal development, 620fig, 628fig, 655–656. See also

pregnancy fetal programming, 622 fetus, 621 fiber

benefits and forms of, 119t carbohydrates high in, 707 for children, 668, 670 dietary, 118 food labels, 62 gluten and, 101 health benefits, 127–129, 150 insoluble, 118 intestinal disorders and, 101–102 needs, 130t for older adults, 704t soluble, 118 sources, 133fig structure, 117fig thermic effect of food, 513t weight loss and, 553–554fig

Fight BAC!, 741fig fish

adding to diet, 193 bioaccumulation of toxins, 737fig intake during childbearing years, 625t safety tips, 738

Fitness Tips energy balance, 519 exercise during pregnancy, 637 get moving, 557, 584 increase NEAT, 516

FITT principles, 582–584, 585t, 612fig 5-methyltetrahydrofolate (5-methyl THF), 379 flatulence, 101 flavanols, as functional food, 16t flavin adenine dinucleotide (FAD), 284,

366–367fig flavin mononucleotide (FMN), 366–367fig flavonoids, 194–195, 322 flavoproteins, 297 flavored water, 418t

I-8 Index

flexibility, 579, 582 flour, processing, 131fig fluid balance. See also water

diuretics, 420, 427 exercise and, 422fig, 604–607fig, 606t, 613fig ICF and ECF, 411fig, 424 older adults, 703fig, 704t, 707 potassium and, 444 proteins, 413–414 regulating, 218–219, 220t role of minerals, 436 sodium and, 439 sports drinks, 606 young children, 670

fluorapatite, 486fig fluoride

daily needs, 486 food sources, 486–487 functions, needs, and sources, 471t metabolic functions, 486 overview, 500 toxicity and deficiency, 471t

fluorosis, 487fig flushing, 371 Focus Figure

atherosclerosis, 191fig calcium homeostasis, 447fig carbohydrate digestion and absorption,

121fig diabetes, 143fig Dietary Reference Intakes, 46fig digestive system, 77 energy balance, 509 energy sources for exercise, 594fig fluid balance during exercise, 422fig hormones regulate blood glucose, 125fig lipid digestion and absorption, 166fig lipoprotein transport and distribution, 171fig metabolism during postabsorptive

state, 303fig Nutrition Facts panel, 60 protein digestion and absorption, 212fig protein synthesis, 215fig retinal and its role in vision, 331fig small intestinal wall, 80

folate activation by vitamin B12, 384fig daily needs, 380 deficiency, 496–497 digestion, 379fig food sources, 380–381 intake during pregnancy, 630 metabolic functions, 379–380 overview, 378–379, 399fig sources and functions, 363t structure, 379fig toxicity and deficiency, 381

folic acid defined, 378 enriched grains, 131fig–132 intake before pregnancy, 624 intake during pregnancy, 625, 627, 630

food additives, 752–760, 753t, 758fig, 759fig, 760fig

food allergens, 652–653fig food allergies, 652–655, 653fig, 658fig

throughout childhood, 677 eight main foods, 653–654fig

Food and Drug Administration (FDA)

agencies overseeing food supply, 748t bottled water regulation, 417 dietary supplement labels, 350fig food additive regulation, 754–755 food labels, 58–59, 59fig, 62 genetically engineered foods, 768–769t

food assistance programs global hunger, 793 U.S., 790t

foodborne illness, 98–99. See also food safety causes, 732–739, 770 high-risk populations, 739 preventing, 739–746, 741fig, 743fig, 744t,

744fig, 745t, 745fig, 770 food deserts, 782–783 food frequency questionnaire, 20 food groups

exchanges, 57t healthy balance, 40 meeting vitamin needs, 325fig, 352t mixing up choices, 52fig

food insecurity, 780–781t among populations, 781–782 illness and disability as factors, 783–784 poverty and, 678 older adults and, 715–716 worldwide, 784fig

food intake overview, 568 portion distortion, 548 regulation, 540–543, 542fig timing, 596–597

food intolerance, 654 food label information, 59fig, 60fi, 65g, 69. See also

Nutrition Facts panel FDA regulation, 58–59 foods from animals, 756–757 health benefit claims, 62–65, 62fig, 63fig,

63t, 64t nutrient values, 58–60 percent Daily Values (%DVs), 61–62

food log, 561fig food pantry, 791 food plan, healthy, 55fig food preservation, 749, 752–753 food processing, added sugars, 135fig–136 food production, environmental impact, 762t food record, 20 foods

energy density, 554fig–555fig interactions with medications and supple-

ments, 711–712 sugar-free, 136fig whole and processed, mineral

content, 440t foods, baby’s first year, 648fig

choices in, drivers, 4fig–7 exchanges, 57t kilocalories, 53t

food safety. See also foodborne illness additives and chemicals, 771 agencies, 748t cooking temperature, 743–744fig, 744t at home, 741–746 during pregnancy, 633 hand washing, 741–742 preservation methods in manufacturing,

749–751 product dating, 751fig

protection of U.S. food supply, 747–752 refrigeration and storage, 744–746, 745t roles in, 770 while traveling, 746

Food Safety Initiative (FSI), 748 food security, 780–781t food storage, vitamins destroyed, 325 food supply

agricultural challenges and food waste, 785–786

increasing through GMOs, 766–767 food system

defined, 732 sustainable, 761fig–764, 762t

food thermometers, 744fig food waste, 785–786 forebrain, effects of alcohol, 257fig, 274fig formula, 646–647 fortified foods

benefits and risks, 326 to meet nutrient needs, 16 reducing malnutrition, 793

free radicals, 160, 322–323fig free range, 757 friends, impact on childhood obesity,

681–682 fructans, and IBS, 102t fructose

absorption and storage, 122fig IBS and, 102t metabolism, 290 structure, 113fig

fruits calcium content, 449fig carbohydrate sources, 130fig, 132 children’s intake, 677t chromium sources, 489fig copper sources, 480fig energy density, 565fig fiber sources, 133fig folate in, 381fig intake during pregnancy, 630fig iron sources, 476fig kilocalorie needs, 53t magnesium content, 453fig manganese sources, 493fig needs for older adults, 703fig nutrient-rich, 52fig phosphorus content, 451fig potassium in, 445fig protein and saturated fat, 233fig protein sources, 229fig selenium sources, 485fig servings for vegetarian diet, 238t sodium content, 441fig vitamin A in, 333fig vitamin B2 in, 369fig vitamin B6 in, 377fig vitamin C in, 389fig vitamin E in, 344fig vitamins in, 325fig, 352fig washing, 742 water content, 419fig weight loss and, 553–554fig zinc sources, 482fig

fuel, and thermic effect of food, 513t functional fiber, 119 functional foods, 15, 16t fungicides, 757

Index I-9

G galactans, and IBS, 102t galactose

absorption and storage, 122fig metabolism, 290 structure, 113fig

galactosemia, 308t, 309fig gallbladder, 77fig, 84fig, 166fig gallbladder disease, 99 gallstones, 99fig gastric bypass, 566fig, 571fig gastric inhibitory peptide (GIP), 94t–95fig gastric juices, 88, 89 gastric lipase, 89 gastric pits, 78 gastrin, 94t–95fig gastritis, 260 gastroenteritis, 98–99 gastroesophageal reflux disease (GERD), 98 gastrointestinal (GI) tract, 76–77fig

digesting and absorbing carbohydrate, 121fig enteric system and, 95–96 flora, 81, 82 food propelled through, 84–85, 105fig hormones regulating digestion, 94t lipid digestion and absorption, 166fig protein digestion and absorption, 212fig secretions, 90t

gender basal metabolism and, 512t effect on alcohol metabolism, 255–256

gene-environment interaction, 544 generally recognized as safe (GRAS), 755 genes

basal metabolism and, 512t body weight and, 544–547, 569 childhood obesity and, 679 effect on alcohol metabolism, 255–256 gene expression, 17–18, 32 genetic disorders, metabolic, 308–310, 313 protein synthesis regulation, 214–216, 215fig unintentional transfer in genetic

engineering, 768 genetic engineering (GE), 766–769t, 767fig

concerns about, 768–769t overview, 771fig regulation in US, 768–769

genetically modified organisms (GMOs), 766–769t, 767fig

genome, 766 germ, 131 gestational diabetes, 146, 637 gestational hypertension, 638 ghrelin, 94t–95fig, 542 Giardia lamblia, 734t glossitis, 368, 369fig glucagon, 124, 125fig, 285t glucagon, metabolic regulation glucogenic amino acids, 220, 221,

291–292fig, 292t gluconeogenesis

amino acids used for, 214fig defined, 123 low blood glucose, 125fig metabolic pathway, 299t protein metabolism, 240fig

glucose. See also blood glucose absorption and storage, 122fig

condensation reaction, 114fig diabetes and, 141–146, 151 in plant cells, 118fig production, 112fig–113 role in energy metabolism, 298t sodium as transport, 439fig structure, 113fig structure, 148fig transformed to pyruvate, 287–289fig utilization during exercise, 588fig–590

gluten free, 100 glycemic index (GI), 133–134fig, 549–550fig glycemic load (GL), 133–134 glycerol

alcohol structure, 248 defined, 162 to pyruvate, 290–293 role in energy metabolism, 298t utilization during exercise, 592fig

glycogen carbohydrates stored as, 300 effects of exercise on, 588fig–590 storage in animals, 119 structure, 117fig

glycogen storage disease, 308t, 310 glycogenesis, 120, 299t glycogenolysis, 123–125fig, 299t glycolysis

metabolic pathway, 288fig, 298fig,299t,312fig conversion to pyruvate, 287–288fig, 289fig

glycosidic bond, 113 goblet cells, 78fig goiter, 489–490fig goitrogens, 491 golden rice,” genetically engineered, 767fig gout, 713–714 grains

calcium content, 449fig carbohydrate sources, 130fig chromium sources, 489fig copper sources, 480fig energy density, 565fig fiber sources, 133fig folate, 381fig intake during pregnancy, 630fig iron sources, 476fig kilocalorie needs, 53t magnesium content, 453fig manganese sources, 493fig nutrient-rich, 52fig older adults, needs for, 703fig phosphorus content, 451fig potassium, 445fig protein and saturated fat, 233fig protein sources, 229fig selenium sources, 485fig servings for vegetarian diet, 238t sodium content, 441fig vitamins in, 325fig, 352fig vitamin B1 sources, 366fig vitamin B3 sources, 372fig vitamin B12 sources, 365fig vitamin B2 sources, 369fig vitamin B sources, 6, 377fig vitamin D sources, 339fig vitamin E content, 344fig water content, 419fig whole grains, 16t, 131–132 zinc, 482fig

growth vitamin A and, 330, 332 vitamins supporting, 319t

growth chart, 648fig, 667fig growth hormone, 126 growth spurt, 682 growth stunting, 794 guanosine triphosphate (GTP), 295 Guiding Stars, 59fig gynoid obesity, 520–521fig

H habits, food choices and, 7 hand washing, 741–742 hangovers, 258–259 Harris-Benedict equation, 705 health claims. See also Nutrition Facts panel

food labels, 62–64, 62fig, 64t probiotics, 82

Health Connection aging and hypertension, 718–720 alcohol use disorder (AUD), 269–272 cancer risk reduction, 392–396 childhood obesity, 687–688 common digestive disorders, 98–102, 104 credible nutrition information, 28–30 diabetes, 141–144, 146–147 disordered eating, 527–531 effects of chronic undernutrition, 794t–795t ergogenic aids and fitness, 609–611 food allergies, 652–655 genetic disorders of metabolism, 308–310 genetically engineered food, 766–769t,

767fig heart disease, 190–196 medical interventions for obesity, 565–567,

566fig nutrient-deficient anemias, 495–497 osteoporosis, 455–459 portion distortion, 65–67 vegetarianism, 236–238 vitamin supplements, 348–350 water balance and exercise, 423

health risks determining by BMI and waist circumference,

526fig overweight or obese, 538–540 underweight, 539

healthy eating. See also balanced diet principles, 40–44 supplements and, 348–350, 353 tools, 43t–44t

Healthy People 2020, 23t healthy weight, 524 hearing, decline in older adults, 701 heart attack, 190 heart disease, 190–196

cause of death, 17t effects of soy, 228 prevention, 710t protein overconsumption and, 232 reducing risk, 190, 192–196, 200 risk factors, 190, 192t

heartburn, 98, 636 heat, effects on vitamins, 326 heat exhaustion, 604–605t heat stroke, 604–605t height and weight tables, 524

I-10 Index

Helicobacter pylori, 99 heme iron, 472 hemeopoiesis, 361 hemochromatosis, 389, 477 hemoglobin, 472, 474–475fig hemolytic uremic syndrome, 735 hemorrhage, 344 hemorrhoid, 102 hemosiderin, 473 hepatic portal vein, 97fig hepatic vein, 97 hepatitis A, 733t hepcidin, 474 hephaestin, 473 herbicides, 757 hexose, 113 high potency,” 350fig high-density lipoproteins (HDLs), 169–170fig,

171fig high-intensity interval training (HIIT), 584–585 high-pressure processing (HPP), 750 histones, 545 homocystinuria, 308t, 309 hormones. See also specific hormone names

antidiuretic (ADH), 414 basal metabolism and, 512t blood glucose levels, 124–127, 149fig calcium balance, 446, 447fig digestive, 93–96, 95fig, 106fig hormone-free labeling, 756 interaction with alcohol, 263 iron absorption regulation, 474 metabolic regulation, 284–285t parathyroid, 336, 338fig prohormone, 336 role of cholesterol, 174 role of proteins, 218, 220t stimulating satiety and hunger, 542fig thyroxine-releasing, 490fig use in livestock, 755–756

hormone-sensitive lipase (HSL), 294, 544 host, 734 hunger. See also food insecurity; malnutrition;

undernutrition carbohydrates and, 549 desire to eat, 541 efforts to reduce, 790t–793 hormones and, 95

hydration. See fluid intake; water hydrochloric acid (HCI), 89, 90t hydrogen ions, pH scale, 88 hydrogenated starch hydrolysates (HSHs) , 140t hydrogenation, 161 hydrolysis, 86, 408 hydrolytic reaction, 208fig hydrophobic, 158 hydrostatic weighing, 521–522t hydroxyapatite, 436 hymocysteine, 190 hypercalcemia, 339 hypercalcemia, 449 hyperchloremia, 443 hyperemesis gravidarum, 632 hyperkalemia, 444–445 hyperlipidemia, 263 hypernatremia, 440 hyperphenylalanemia, 308 hyperphosphatemia, 452 hyperplasia, 543

hypertension. See also blood pressure; sodium aging and, 718–720 DASH diet, 441 defined, 192 diuretic treatment, 420 during pregnancy, 637–638 older adults, 724 prepregnancy, managing, 627 prevention, 710t severe obesity and, 565–567 sodium excess and, 440 vitamin D and, 337

hyperthermia, 604 hypertriglyceridemia, 177 hypertrophy, 543 hypervitaminosis, 320 hypervitaminosis A, 334 hypervitaminosis D, 339 hypocalcemia, 449 hypochloremia, 443 hypoglycemia, 126 hypokalemia, 420 hyponatremia, 421 hypophosphatemia, 452 hypothalamus, 414–415fig, 424, 427fig, 541,

542fig, 568fig hypothermia, 605 hypothesis, 24–27, 25fig hypothyroidism, congenital. See cretinism hypotonic, 442 hypovolemia, 424

I ileocecal valve, 81 illness. See disease; foodborne illness; virus; indi-

vidual disease names immune system

beneficial bacteria, 83t decrease in function, 701 food allergies and, 652–653 impaired immune response,

prevention, 710t iron and, 475 physical fitness and, 581t proteins and, 220t regulation by vitamin D, 337 vitamin A and, 330, 332 vitamin C and, 388 vitamins supporting, 319t weakened, effects of malnourishment, 795 zinc and, 481–482

immunity, 220, 221 impaired glucose tolerance. See prediabetes impaired immune response, prevention, 710t incomplete protein, 227, 229 incubation period, 734 indigestion, 98 infants

breastfeeding, 349, 640–646, 656 formula, 647, 657 iron needs, 649 low birthweight, 624–625 malnutrition, at risk for, 788–789 nutrition needs, 648fig–650 rickets in, 339–340fig solid foods, 650–652, 657 specific nutrient needs, 657fig

inflammatory bowel disease (IBD), 104

information, evaluating, 28–30, 34 ingestion, 77fig inorganic elements, minerals as, 434 inorganic nutrients, 8–9 inositol, 392 insecticides, 757 insensible water loss, 411 insoluble fiber, 118–119fig insulin. See also diabetes

carbohydrates and, 549 blood glucose regulation, 124 chromium and, 488 food intake and–542fig metabolic regulation, 285t

insulin resistance, 141 integrated pest management (IPM), 759 intensity

effects on fat loss, 558–560, 559fig effects on glucose and glycogen, 589 FITT principles, 582–584, 585t, 612fig use of fat, 592

intentional food additives, 755 international units (IU), 332 Internet, evaluating information, 29–30 interstitial fluid, 411 interstitial spaces, 218 interviews, nutrition assessment, 19–20 intestinal bacteria, link to obesity, 556–557 intestinal permeability, 91–92 intracellular fluid (ICF), 411fig, 424 intravascular fluid, 411 intrinsic factor (IF), 382 intrinsic factor, 89, 90t iodide, 489 iodine

daily needs, 490 food sources, 490–491fig functions, needs, and sources, 471t metabolic functions, 490 overview, 489, 500 toxicity and deficiency, 471t, 491

iodopsin, 330 ion channels, proteins as, 219fig ions, 9 iron

absorption and transport, 473t–474fig absorption, vitamin C and, 387 adolescents’ needs, 683 vegetarian diet, 237 daily needs, 475–476 deficiency, 477 deficiency in athletes, 601 food sources, 476fig functions, needs, and sources, 471t infant’s needs, 649 intake during pregnancy, 630–631 metabolic functions, 474–475 needs in older adults, 704t, 708–709 needs in young children, 668–670 overview, 472, 498fig oxidation, 475, 479fig toxicity, 476–477 toxicity and deficiency, 471t

iron-deficiency anemia, 495–496 iron overload, 477 irradiation, 750–751fig irritable bowel syndrome (IBS),

83t, 102 isoflavones, 228

Index I-11

J jaundice, 637 jejunum, 79fig joints, problems with, 713–714

K kcalories. See kilocalorie keratinization, 335 Keshan disease, 485 keto acid, 216 ketoacidosis, 152, 305 ketogenesis, 299t, 304fig–305 ketogenic amino acids, 287, 292fig, 292t ketone bodies, 123, 304fig ketosis, 123 kidneys

diabetes and, 146 hypertension and, 414–415fig kidney disease, fatal, 17 potassium and, 443–444 sodium balance and, 438–440 water excretion and, 410 vitamin C toxicity and deficiency, 389

kidney stones calcium and, 448 potassium and, 444fig, 462fig protein overconsumption and, 232–233

kilocalories, 553 alcoholic drinks, 262fig from alcohol and energy-yielding

nutrients, 10fig defined, 9–10 food group choices, 53t food label content claims, 63t needs in second and third trimesters, 635–636 limiting, 50 needs for breastfeeding mothers, 644 needs for school-age children, 673fig, 676t overconsumption in children, 679 restriction, and lifespan, 706 used during activities, 557t using MyPlate, 53–55

kosher certification, 747 Kreb’s cycle. See tricarboxylic acid (TCA) cycle kwashiorkor, 234–235fig

L labels. See dietary supplement labels; food labels;

Nutrient Facts panel laboratory experiment, 26 lactate

converted from pyruvate, 290fig–291fig from acetyl CoA, 293fig

lactation, 640 lacto-ovo-vegetarian, 236 lacto-vegetarian, 236 lactose, 116

amount in foods, 115t IBS and, 102t lactose intolerance, 115–116 lactose maldigestion, 115

lanugo, 529 large intestine, 77fig, 81, 83. See also colon

digesting and absorbing carbohydrate, 121fig fluid absorption, 93 lipid digestion and absorption, 166fig water excretion and, 410fig–411

lateral hypothalamus, 541–542fig, 568 leaky gut syndrome. See intestinal permeability lean body mass (LBM), 511, 512t least developed country, food insecurity, 784 lecithin, 164 legumes

as carbohydrate source, 132 servings for vegetarian diet, 238t

leptin, food intake and–542fig letdown response, 640–641fig leukemia, 392t, 393 licensed dietitian nutritionist (LDN), 28 life expectancy, 698 lifespan, 698, 699 lifestyle. See also diet; exercise

effects on osteoporosis, 457–459 food choice habits, 7 health effects in older adults, 699–700 moderate alcohol consumption and, 267 NEAT and, 514–516 pre-pregnancy, 623–627, 655

light effect on rhodopsin, 331fig effect on vitamins, 325

lignin, 118 limiting amino acid, 226 linoleic acid, 161, 182fig linoleic and linolenic acid, 173fig–174 lipases, 167 lipid accumulation, arterial, 191fig lipids. See also fatty acids

absorption, 166fig, 169fig, 198 chemical composition, 9fig, 31fig digestion, 198fig digestion, absorption, and transportation,

165–171, 198 fatty acid composition, 158–162 functions, 172–175 phospholipids, 165fig primary role, 12t, 13, 32 sterols, 164 structure, 206fig transportation, 169–171fig triglycerides, 162–164 triglycerides, 162fig–164

lipogenesis, 124 lipoic acid, 392 lipolysis

insulin and, 124 energy metabolism overview, 298fig fatty acid oxidation, 294fig, metabolic pathway, 299t

lipoprotein lipase (LPL), 168, 544 lipoproteins, 168–170fig Listeria monocytogenes, 633, 655, 740 liver, 77fig, 84fig

alcohol metabolism, 252–254fig, 253fig, 273 choline and, 391 digesting and absorbing carbohydrate, 121fig glycogenolysis regulation, 124 lipid digestion and absorption, 166fig metabolizing alcohol, 305–307, 306fig, 312fig monosaccharide transportation, 122fig protein digestion and absorption, 212fig role in metabolism, 284

liver disease, alcohol and, 263–264fig, 274 locally grown food, 764 locavores, 764 long-chain fatty acids, 160

longevity, 267, 698 low birthweight, 624 low-density lipoproteins (LDLs), 169–170fig,

171fig, 195t low-energy-dense foods, 42–43t lower esophageal sphincter (LES), 78fig low FODMAP foods, 102t Lp(a) protein, 190, 192 lubricant, water as, 308 lumen, 76 lunch. See also Table Tips

food plan, 55fig saturated fat, 186t carbohydrate-loading, 592t school lunches, 675–676t, 790t

lungs, and water excretion, 410fig–411 lycopene, as functional food, 16t lymph, lipids absorbed into, 167–168 lymphatic system, nutrient distribution,

96fig–97, 107fig lymphoma, 392t

M macrocytic anemia, 496–497, 501 macrominerals. See major minerals macronutrients

functions of, 12t structure, 206fig timing intake with exercise, 597t–599

macrophages, 190 macrosomia, 637 magnesium

daily needs, 453 food sources, 453fig functions, needs, sources, toxicity, and

deficiency, 437t metabolic functions, 452–453 overview, 462 toxicity and deficiency, 454

major minerals, 14, 434, 435fig, 461fig malabsorption, 19. See also celiac disease malaria, 795t malignant, 393 malnutrition. See also hunger; undernutrition

defined, 19 contributing factors in U.S., 780–784, 781t,

782fig, 796 digestive disorders, 101, 107 global, 784fig–787 populations at greatest risk, 788–789 primary, 260, 261 protein-energy, 234–235, 242 secondary, 261 Wernicke-Korsakoff syndrome, 261

maltose, 114fig, 116 manganese

daily needs and sources, 492–493fig functions, needs, and sources, 471t metabolic functions, 492 overview, 501 toxicity and deficiency, 471t, 493–494

mannitol, 140t maple syrup urine disease, 308t, 309 marasmus, 235fig marine toxins, 737 mass movement, 85 mast cells, 652 mastication, 76

I-12 Index

matrix Gla protein, 346 meal composition

thermic effect of food and, 513t effects on physical activity, 596–598, 613 energy content, 510

meals, frequent, for young children, 666–668 Meals on Wheels, 717, 790t meat, cooking thoroughly, 743fig mechanical digestion, 76–77fig media, childhood obesity and, 681 medical nutrition therapy, 28 medications. See also supplements

diuretics, 420 interactions with supplements and foods,

711–712 treating alcoholism, 271 weight-loss, 565–566

Mediterranean diet, 179–181 medium-chain fatty acids, 160 megadose, vitamin, 320 menadione (vitamin K3), 345fig menaquinone (vitamin K2), 345 menarche, 682 Menkes’ disease, 480 menstrual dysfunction, 603–604 mental health, and physical fitness, 581t messenger RNA (mRNA), 215fig, 216 metabolic pathways, 282, 283, 299t, 312,

305–307, 306fig metabolic programming, 622 metabolic syndrome

alcohol consumption and, 267 chromium and, 488 type 2 diabetes and, 142

metabolic water, 410 metabolism. See also absorption; excretion,

recycling; transport absorption, 300–302, 301fig, 305t, 312 alcohol, 252–256, 254fig, 253fig, 273,

305–307, 306fig, 312fig amino acids, 213–217, 214fig ATP, 586fig basal, 511 biotin, 374–375fig B vitamins function in, 361–362fig calcium, 446, 448 chemical reactions and, 282fig–283, 311 chloride, 442 copper, 479 defined, 282–283 feeding and fasting, 305t folate, 379–380 food, 288fig fructose and galactose, 290 fueled by ATP, 285–287, 311 genetic disorders, 308–310, 313 iodine, 490 iron, 474–475 liver’s role, 284 magnesium, 452–453 older adults, 704–705, 723 overview, 298fig pantothenic acid, 373 phosphorus, 451 regulation of, 284–285t role of individual nutrients and alcohol, 298t selenium, 484fig sodium, 439 stages of, 282fig

sulfate, 454–455 vitamin B1, 365fig vitamin B3, 370, 371fig, 376 vitamin B2, 367–368fig vitamin C, 387–388 vitamin D, 336–337fig vitamin E, 342–343 vitamins and minerals contributing to, 599 within cells, 283fig zinc, 481–482

metalloenzymes, 470 metallothionine, 481 metastasize, 393 methionine, 454fig, 463fig methylcobalamin, 382–383fig methylmercury, 738–739 micelles, 167, 198fig microbiome, link to obesity, 556–557 microcytic anemia, 495fig–496, 501 microcytic hypochromic anemia, 378 microminerals. See trace minerals micronutrients, 12t micronutrients, intake during pregnancy, 629–630fig micronutrients, role in normal cells, 394fig microsomal ethanol oxidizing system (MEOS),

254, 273, 306 microsomes, 254 microvilli, 80fig, 81 milestones, 648fig milk. See also calcium; dairy; lactose

balanced diet and, 15–16 Dietary Guidelines for Americans, 50–51 lactose intolerance and, 115–116 nutrient-density, 41–42 children, recommendations for, 340. See also

breastfeeding and breast milk mineral water, 418t mineralization, 436 minerals. See also major minerals; supplements;

trace minerals; specific mineral names amounts in body, 435fig, 461fig athletic performance and, 599, 601–602, 613 bone health and, 463 chemical composition, 9fig, 31fig food label information, 60fig functions, needs, and sources, 437t nonessential nutrients, 494, 501 overview, 434–437 primary role, 12t, 14, 32 toxicity and deficiency, 437t

mitochoncrion, 283fig mobility, decreased in older adults, 712–713 moderate diet, 40, 41 moderate drinking, 251 modified atmosphere packing (MAP), 750 molds, 736 molecules, 9 molybdenum

functions, needs, and sources, 471t overview, 492, 500 toxicity and deficiency, 471t

monoglycerides, 167 monosaccharides

absorption and storage, 122fig carbohydrates absorbed as, 120 defined, 113–114fig

monosaturated fatty acid (MUFA), 160 monosodium glutamate (MSG), 754 monounsaturated fats, 183fig

morning sickness, 632–633 mouth

digesting carbohydrate, 120, 121fig, 148fig lipid digestion and absorption, 166fig, 167 protein digestion and absorption, 212fig role in digestion, 76–78, 77fig

movement, proteins enabling, 218 mucosal block, 477 mucus, 79, 90t multi-metabolic and hormonal disease state,

obesity as, 538 muscles

calcium and, 446 contraction, potassium and, 444 contraction, sodium and, 439 endurance, 578–579, 582 iron needs, 683 older adults, decline in mass, 701 protein’s role, 595–596 strength, 578–579, 582

myelin sheath, 383 myoglobin, 472, 475fig, 743 MyPlate

anatomy of, 49fig, 69fig calcium content, 449fig carbohydrate sources, 130fig changes in diet, 51–53 chromium sources, 489fig compared to Mediterranean diet, 181 copper sources, 480fig energy density, 565fig essential fatty acid sources, 182fig fiber sources, 133fig folate source, 381fig iodine sources, 491fig iron source, 476fig kilocalorie needs, 52 magnesium content, 453fig manganese sources, 493fig nutrient needs during pregnancy, 630fig for older adults, 703fig omega-3 fatty acid sources, 182fig phosphorus content, 451fig potassium sources, 445fig protein and saturated fat, 233fig protein sources, 229fig school-age children’s needs, 673–675, 689 selenium sources, 485fig sodium content, 441fig tool for healthy eating, 43t–44t vitamin A content, 333fig vitamin B1 sources, 366fig vitamin B3, ,sources, 372fig vitamin B12 sources, 365fig vitamin B2 sources, 369fig vitamin B6 sources, 377fig vitamin C sources, 389fig vitamin D content, 339fig vitamin E content, 344fig vitamin K content, 347fig vitamin needs, 325fig water content, 419fig zinc sources, 482fig

My Vegan Plate, 237fig

N National School Lunch Program, 790t natural disasters, factor in food shortage, 786

Index I-13

natural resources depletion, and food shortage, 786 locally grown food, 764 sustainable food system, 762–763

natural sugars, 134–135fig negative energy balance, 508–509 neotame, 140t nerve impulse

potassium and, 444 sodium and, 439

nerves, calcium and, 446 nervous system, regulating digestion, 93–96,

106fig. See also enteric nervous system neural tube, folding, 625fig neural tube defects, 380 neural tube development, 380 neuropeptide Y (NPY), food intake and–542fig niacin (B3). See vitamin B3 niacin equivalents (NE), 370–371 nickel, 494 nicotinamide adenine dinucleotide (NAD+), 284,

369–370fig night blindness, 335 night eating syndrome, 530 nitrites and nitrates, 753 nitrogen balance, 221–223, 222fig, 241fig non-celiac gluten sensitivity (NCGS), 101 nonessential amino acids, 207, 216–217fig,

208t, 240 nonessential nutrients, 8–9 nonexercise activity thermogenesis (NEAT),

514–516 nonheme iron, 472 norepinephrine, 124 norovirus, 733t, 735 nucleus, 283fig nutrient absorption, 90, 92fig–93 nutrient content claims, food label information,

62fig, 63t nutrient density, 50 nutrient-deficiency diseases, 17, 32 nutrient-deficient anemias, 495–497, 501 nutrient-dense diet, 40–42 nutrient requirements, 44 nutrients. See also digestion; and entries for specific

nutrients absorption, 90, 92fig–93 balanced diet and, 15–16 chemical composition in food, 9fig defined, 8–9 food additives and, 754 food label content claims, 62fig, 63t fortified foods and supplements, 16, 326 in foods and body, 8fig nutrient-dense foods, 52fig six classes, 9fig, 12t–14, 31t, 32 transportation, 96–97, 107fig

nutrigenomics, and weight control, 544–545 nutrition. See also entries for specific nutrients

alcohol interfering with, 260–261, 263 assessing status, 18–22 defined, 7–10 knowledge of, 6 long-term effects of alcohol, 260–263 meeting needs, 15–16 methods for assessing, 19–21

nutritional genomics, 18 Nutrition Facts panel, 43t–44t, 59–61, 133fig. See

also food label information

Nutrition in Practice adolescent diet and therapy plan, 686 anemia, 478 athlete, diet plan for, 600 blood cholesterol levels, 197 bone mineral density, 460 diabetes risk, 145 irritable bowel syndrome, 103–104 older adult hypertension, 721–722 pregnancy, 634–635 vegan diet, 239 vitamin B12 deficiency, 386 vitamin D deficiency, 341 weight gain, 562

Nutrition Labeling and Education Act (NLEA), 58

nutrition transition, malnutrition and, 787 nuts

allergies, 654 as carbohydrate source, 132 increasing intake, 194–195 PDCAAS, 226–227 peanut butter amino acid scores, 225t servings for vegetarian diet, 238t

O obese, 524–525t obesity. See also overweight; severe obesity

American diet and, 23fig in children. See childhood obesity calcium and, 448 cancer risk and, 393 central, 520–521fig classification methods, 525t fiber and, 129 gynoid, 520–521fig health risks, 538–539 link to microbiome, 556–557 NEAT and, 516 nutrition transition and, 787 poverty and, 789 prevention in older adults, 710t sugar-sweetened beverages and, 137t–139 thermic effect of food and, 513t

observational research, 26 oils, 160. See also fat, dietary

composition, 183fig, 184t energy density, 565fig hydrogenation, 186–187 intake during pregnancy, 630fig kilocalorie needs, 53t needs for older adults, 703fig, 704t nutrient-rich, 52fig vitamin D sources, 339fig vitamin E content, 344fig vitamin K content, 347fig

older adults. See also aging aging-related health concerns, 723 changing metabolism, 723 community resources, 717 decreased mobility, 712–713 dietary changes, 704t factors affecting nutrition, 724 malnutrition, at risk for, 789, 796 moderate alcohol consumption, 266 nutritional needs, 703–711 nutrition-related health concerns,

711–715

preventing age-related disorders, 710t use of supplements, 349

olestra, 189 oligosaccharide, 116fig–117 omega-3 fatty acid, 161

as functional food, 16t sources, 182fig and vegetarian diet, 238

omega-6 fatty acid, 161 1,25-dihydroxycholecalciferol, 336 oncogenes, 393 open dating, 751fig organelles, 283 organic foods, 759–760fig organic nutrients, 8–9 organophosphates, 757 organs. See also entries for individual organs

accessory, 84, 105fig, 121 digestive, 76–84

orthorexia, 530 osmolality, 412 osmosis, 218, 411–412fig osmotic gradient, 412 osmotic pressure, 412 osteoarthritis, 713fig osteoblasts, 336 osteocalcin, 346 osteoclasts, 336 osteomalacia, 340 osteopenia, 457 osteoporosis

protein overconsumption and, 233 decreased mobility, 714 excessive vitamin A and, 334 in athletes, 603–604 lifestyle factors, 457–459 overview, 455–456, 463 preventing, 459, 710t sodium overconsumption and, 441

other specified feeding or eating disorder (OSFED), 528t, 529

overexercise, 579 overnourished, 19 overnutrition, poverty and, 789 overpopulation, and food shortage, 786–787fig overweight

classified, 525t defined, 524–525t health risks, 538–539

ovo-vegetarian, 236 oxaloacetate, 295 oxidation, iron, 475, 479fig oxidation-reduction reactions, 284fig oxidative phosphorylation, 296–297, 299t oxidative stress, 322, 323fig oxygen, effect on vitamins, 325

P pancreas

digesting and absorbing carbohydrate, 121fig

digestive juices, 84fig digestive process and, 77fig enzymes and actions, 88t lipid digestion and absorption, 166fig protein digestion and absorption, 212fig

pancreatic amylase, 120 pancreatic juice, 88

I-14 Index

pantothenic acid daily needs, sources, and metabolic functions,

373–374 overview, 373, 398fig sources and functions, 363t toxicity and deficiency, 374

paralytic shellfish poisoning, 737 parasites, 734t, 736 parathyroid hormone (PTH), 336, 338fig parietal cells, 78 Parkinson’s disease, prevention, 710t passive diffusion, 92fig–93, 106fig pasteurization, 749 pathogens, causing foodborne illness, 732–736,

733t–734t peak bone mass, 456 peanut butter

amino acid scores, 225t PDCAAS, 226–227

peer-reviewed journal, 25 pellagra, 372fig pentoses, 365 pepsin, 89 pepsinogen, 89 peptide, 207 peptide bonds, 207, 240 peptide YY (PYY), 94t–95fig, 542fig percent body fat, 521 percent Daily Values (%DVs), food label infor-

mation, 61–62 percentile, 648 peripheral neuropathy, 366 peristalsis, 85fig, 105fig pernicious anemia, 385, 497 pescetarian, 236 pesticides, 757–759, 758fig

EPA’s risk assessment, 758fig minimizing, 759fig

pH acid-base balance, 409 changes, effects on vitamins, 325–326 pH scale, 88 regulation by proteins, 219, 220t vitamin B1 and, 364

pharynx, 77fig, 78 phenylalanine hydroxylase, 310 phenylketonuria (PKU), 308t–309 phospholipases, 167 phospholipids

cell membranes, role in, 174fig–175 phosphorous, formed from, 451fig structure, 164 fig–165, 198fig unnecessary in diet, 177

phosphorus, 450–451, 462fig daily needs, 451 food sources, 451fig functions, needs, sources, toxicity, and

deficiency, 437t metabolic functions, 451 toxicity and deficiency, 452

photosynthesis, 112fig–113 phylloquinone (vitamin K1), 345fig physical activity. See exercise physical activity pyramid, 584fig physical exam, nutrition assessment, 21 physical fitness. See also conditioning; exercise

fitness program, 580–585 five components, 578–579, 612 health benefits, 579–580t, 581t

roles of vitamins and minerals, 599, 601–602, 613

physiologic age, 701 physiological fuel values, 510 phytochemical color guide, 324t phytochemicals

defined, 15 increasing intake, 194 from wine and beer, 266

phytostanols, 165 phytosterols, 165 pica, 530, 633 placebo, 27 placenta, 621fig plant, glucose in cell, 118fig plant sterol and stanol esters, as functional

food, 16t plant-based foods. See also fruits; vegetables

increasing intake, 193, 194 whole plants, 130, 150

plaque, arterial, 190, 191fig plaque formation atherosclerosis, 191fig platelets, 190 political sanctions, factor in malnutrition, 785 polychlorinated biphenyls (PCBs), 738 polyols, and IBS, 102t polyp, colon, 104fig polypeptide, 207 polysaccharides, sugar units, 117–119 polyunsaturated fats, 183fig polyunsaturated fatty acid (PUFA), 160 portion size

dietary guidelines, 50 food intake and, 548 healthy eating and, 41 portion distortion, 65–67 visual approximation, 66fig, 70fig

positive energy balance, 508–509 postabsorptive state, 300, 302–305, 303fig, 312.

See also fasting potassium, 462

balance, 443 channels to pass through, 219fig daily needs, 444 food sources, 440t, 444 functions, needs, sources, toxicity, and

deficiency, 437t metabolic functions, 443–444 toxicity and deficiency, 444–445

potatoes, comparing types, 42fig poverty

child nutrition and, 678 effects in older adults, 715–718, 724 food insecurity and, 782–783 low-income pregnant women, 639–640 overnutrition, risk for, 789

prebiotics, 82–83 prediabetes, 142, 144 preeclampsia, 638 preembryonic period, 620fig–621 pregnancy

adolescents, 638–639 alcohol consumption and, 268–269 first trimester, 620fig, 628fig–633, 655 important health behaviors, 623–627 low-income mothers, 639–640 malnutrition, risk for, 788, 796 negative factors, 640t nutrient needs, 630fig

older mothers, 639 pre-pregnancy lifestyle, 623–627, 655 recommended weight gain, 629t second trimester, 620fig, 635–638, 636t, 656 situation-specific risks, 565, 638–639 supplements and, 349 third trimester, 620fig, 656 trimesters, overview, 655

pregnancy-induced hypertension (PIH), 638 prenatal development, key events,

620fig–622fig, 621fig preschoolers, 666. See also children, young preservatives, 752–753 primary malnutrition, 260, 261 primary structure, protein, 209 prions, 736 prior-sanctioned, 755 probiotics, 16t, 82–83 progressive overload principle, 585 prohormone, 336 proof, alcohol, 250 proportionality, 51 propulsion, 76, 77fig proteases, 89 protein. See also amino acids

Acceptable Macronutrient Distribution Range (AMDR), 224, 241

best food sources, 225–232, 229fig calcium content, 449fig carbohydrate sources, 130fig chemical composition, 9fig, 31fig chromium sources, 489fig copper sources, 480fig daily intake, 221–224, 241 determining needs, 223–224 digesting and absorbing, 211–213, 212fig,

213t, 240 energy density, 565fig excess, 217 exchange system, 55–58 fiber sources, 133fig fluid regulation, 413–414 folate source, 381fig from carbohydrates, 123 functions, 217–221, 220t, 241 in second and third trimesters, 635–636 intake during pregnancy, 630fig iodine sources, 491fig iron sources, 476fig kilocalorie needs, 53t magnesium content, 453fig manganese sources, 493fig metabolism and synthesis, vitamins

supporting, 319t metabolism during feeding and fasting, 305t nutrient-rich, 52fig older adults, needs for, 703fig–704t, 705 organization and shape, 208–210, 209fig overconsumption, 232–234 overview, 206–210 phosphorus content, 451fig potassium, source 445fig primary role, 12t, 13, 32 recommended intake, 223fig saturated fat and, 233fig selenium sources, 485fig sodium content, 441fig sources, 229fig structure, 206fig

Index I-15

timing intake with exercise, 597t–599 transport proteins, 219–220 underconsumption, 234–235 unintentional transfer in genetic

engineering, 768 use during exercise, 586, 588, 591,

595–596, 612 vegetarian diet and, 237 vitamin A sources, 333fig vitamin B1 sources, 366fig vitamin B3 source, 372fig vitamin B12 source, 365fig vitamin B2, source, 369fig vitamin B6 source, 377fig vitamin D sources, 339fig vitamin E content, 344fig vitamin K and, 346 vitamins in, 325fig, 352fig water content, 419fig weight loss and, 555 young children, needs for, 668 zinc source, 482fig

protein bars, 231 protein-based fat substitutes, 188t protein digestibility corrected amino acid score

(PDCAAS), 226–227 protein-energy malnutrition, (PEM), 234 protein shakes and powder, 231 protein synthesis, 214–216, 215fig protein turnover, 214fig, 240fig proto-oncogenes, 393 provitamin-A carotenoids, 328 psychiatric disorders. See eating disorders psychology

mental health and physical fitness, 581t older adults, 717–718, 724 overweight or underweight risks, 539–540

puberty, 682 public health nutritionists, 28 pyramid, Mediterranean diet, 180fig pyridoxal phosphate (PLP), 376fig, 377fig pyruvate

from amino acids and glycerol, 290–293 conversion to acetyl CoA, 293fig glucose, formed from, 287–288, 289fig TCA cycle, 296fig

Q quackery, 28–29 quaternary structure, 210 questionnaires, nutrition assessment, 19–20

R race, basal metabolism and, 512t raffinose, 116 rancidity, 160, 161fig rating of perceived exertion (RPE), 582 reabsorption, sodium, 414–415fig, 420 Recommended Dietary Allowance (RDA), 45,

46fig, 48t. See also Dietary Reference Intakes

(DRIs) carbohydrates, 129–130 protein, 223fig

rebaudioside A, 140t recombinant bovine somatotropin (rBST),

755–756

recombinant DNA technology, 766 rectum, 77fig, 83 recycling

bile, 89 iron, 474 zinc, 481

red blood cells, 495fig, 501fig. See also blood; anemia

folate deficiency, 381fig vitamins supporting, 319t

redox reaction, 284fig, 368fig refined grains, 132 refrigeration and storage, 744–746, 745t registered dietitian nutritionist (RDN), 18 relative energy deficiency in sports (RED-S),

603fig–604 renin, 414 repetition maximum (RM), 583 reproduction. See also pregnancy

vitamin A and, 330, 332 vitamins supporting, 319t

research, nutrition, 24–27 resistance training, 559, 578–579, 582 resistant starch, 117–118 respiratory illness, acute, cause of death, 795t resting metabolic rate (RMR), 512 resveratrol, 266 retinal, 328–329fig retinal, role in vision, 331fig retinoic acid, 328–329fig retinoids, 328 retinol, 328–329fig retinol activity equivalents (RAE), 332 rheumatoid arthritis (RA), 713 rhodopsin, 330, 331fig, 352fig riboflavin (vitamin B2). See vitamin B2 ribosomes, 214, 283fig rickets, 24–25, 339–340fig risk assessment, pesticides, 758 rodenticides, 757 rods, 330 R protein, 382

S saccharin, 140t saliva, 76, 88, 90t salivary amylase, 120 salivary glands, 77fig, 84fig

digesting and absorbing carbohydrate, 121fig enzymes and actions, 87t lipid digestion and absorption, 166fig

Salmonella, 734t, 99 salt. See sodium; sodium chloride sarcoma, 392t sarcopenia, 701 satiation

desire to eat, 541 low-energy-dense foods, 42–43t role of proteins, 220t–221 sugar-sweetened beverages and, 138

saturated fats, 54fig, 54t, 183fig, 186t. See also fat, dietary

balanced diet, fitting in, 54fig, 54t heart disease and, 193 kilocalories, limiting, 50 in protein, 233fig sources low in, 181–182, 185

saturated fatty acid, 160fig

school-age children, 673. See also children; adolescents; young children, dietary needs

School Breakfast Program, 790t school lunches, 675–676t, 790t scientific consensus, 25fig scientific method, 24–25fig, 33 scombrotoxic fish poisoning, 737 scurvy, 389fig seafood. See fish secondary malnutrition, 261 secondary structure, protein, 209 secretin, 94t–95fig secretions, digestive, 89–90 seeds, as carbohydrate source, 132 segmentation, 85fig, 105fig selectively permeable, 411–412 selenium

daily needs, 484 food sources, 484–485fig functions, needs, and sources, 471t metabolic functions, 484fig overview, 499fig toxicity and deficiency, 471t, 485

selenosis, 485 Self-Assessment

alcohol use disorder (AUD), 269 calcium intake, 458 DETERMINE checklist, 716 eating disorders, 531 energy and environment, 547 fat intake, 176 fat-soluble vitamins, 327 family tree, health of, 19 fitness recommendations, 608 food safety habits, 746 food security, 783 pregnancy, healthy, 623 proportionality, 51 type 2 diabetes, 144 water-soluble vitamins, 364

self-weighing, 564 semivegetarian, 236 senescence, 698 sensory abilities, decline in older adults, 701–702 serving size. See also portion size

evaluating, 65–67, 70fig food label information, 60fig, 61 Nutrition Facts panel, 60fig vs. portion, 65–66

“set point,” 546 severe obesity

defined, 524–525t medical interventions, 565–567 treating, overview, 571fig

sexual assaults, college binge drinking and, 270fig

Shigella, 734t short-chain fatty acids, 159, 160 sickle cell anemia, 216 side chain, 207 silicon, 494 simple carbohydrates, 113 single-nucleotide polymorphisms, 546 sitosterol, 165fig skin, and water excretion, 410fig–411 skin cancer, vitamin D and, 340 skinfold caliper, 522t–523 sleep disruption, alcohol and, 258 sleep, and physical fitness, 581t

I-16 Index

small intestine, 77fig, 79fig–81 alcohol absorption, 252–253fig, 273 amino acid absorption, 211 digesting and absorbing carbohydrate,

121fig, 148 enzymes and actions, 88t food intake and–542fig GI tract hormones, 94t–95fig, 106fig iron absorption and transport, 474fig lipid digestion and absorption, 166fig, 198fig nutrient absorption, 92fig protein digestion, 211, 212fig, 240 segmentation, 85fig selenium metabolism, 484fig zinc absorption, 481fig

small for gestational age (SGA), 625 smoking

effects on bone mass, 458 hypertension and, 720 pregnancy and, 626 quitting, 195

smooth endoplasmic reticulum, 283fig snacks

food plan, 55fig saturated fat, 186t for young children, 666–668

social drinking, 251 social life, food choices and, 5–6 socioeconomic status. See also poverty

child nutrition and, 678 food insecurity, 782–783 hunger in America, 791 older adults, 715–718, 724 pregnant women, 639–640

sodium absorption, transport, and excretion, 438–439 daily intake, 439fig–440 DASH diet, 441 deficiency, 442 effect on blood pressure, 414–415fig, 427fig food labels, 62, 63t food sources, 440t functions, needs, sources, toxicity, and

deficiency, 437t hyponatremia, 421 levels, 438fig, 461fig metabolic functions, 439 need in older adults, 704t, 708–709 overconsumption, 440 reducing intake, 50, 441–442

sodium chloride, 442fig, 461fig sodium-potassium pump, 412–413fig soil, sustainability and, 762–763 solanine, 738 solid foods, 650–652 solubility, 13 soluble fiber, 118–119fig solvent, 407 sorbitol, 140t soy protein, as functional food, 16t sparkling water, 418t Special Supplemental Nutrition Program for

Women, Infants and Children (WIC), 790t

specific heat, 407 sphincters, 76, 78fig spina bifida, 380fig spirits, 250t spores, 749–750

sports anemia, 601 sports bars and shakes, 610–611 sports drinks, 606 Spotlight

breastfeeding at work, 645 carbohydrate loading, 591t–592t Dietary Guidelines for Americans, 50–51 farmers markets, 765 hunger in U.S., 791 lactose intolerance, 115–116 Listeria, 740 protein supplements, 231–232 relative energy deficiency in sports (RED-S),

603fig–604 spring water, 418t Staphylococcus aureus, 732, 734t starch, 117fig –118, 148fig starvation. See also malnutrition

basal metabolism and, 512t symptoms in children, 795fig

sterols, 165fig, 198fig stevia, 139 stomach, 77fig, 78, 79fig. See also digestion

alcohol absorption, 252–253fig, 273 alcohol metabolism, 252–253fig, 273 digesting and absorbing carbohydrate, 121fig enzymes and actions, 87t ghrelin from, 542 GI tract hormones, 94t–95fig, 106fig iron absorption and transport, 474fig lipid digestion and absorption, 166fig peristalsis, 85fig protein digestion, 211, 212fig, 240 selenium metabolism, 484fig zinc absorption, 481fig

stomatitis, 368 stool

constipation, 102 diarrhea, 83, 101, 795t diverticulosis, 127fig traveler’s diarrhea, 746

strength training. See conditioning; exercise; resistance training

stress. See also depression basal metabolism and, 512t breastfeeding and, 643 eating behaviors and, 560–561 vitamin C and, 388

stretching, 582 stroke, cause of death, 17t, 190 stroke volume, 581 structure/function claims, food labels, 63–65 subcutaneous fat, 519–520fig substrate, 86 sucralose, 140t sucrose, 116, 140t, 148fig sudden infant death syndrome (SIDS), 626 sugar alcohols, 136 sugar substitutes, 136, 139 sugar-free foods and beverages, 136fig sugar. See also added sugars; specific sugar names

alcohol, 249 comparing types, 134–136, 139–141, 150 food label content claims, 63t in polysaccharides, 117–119 sweeteners, 140t

sulfate daily needs, 455 food sources, 455

functions, needs, sources, toxicity, and defi- ciency, 437t

metabolic functions, 454–455 overview, 463 toxicity and deficiency, 455

sulfites, 454, 753 Summer Food Service Program, 790t sunshine vitamin, 335 SuperTracker, 675fig superweeds, concerns in genetic engineering, 768 Supplemental Nutrition Assistance Program

(SNAP), 790t supplements, 16

amino acid, 610 antioxidant, 324 beta-carotene, overconsuming, 334 calcium, 449–450 checklist, 709t dietary label, 350fig lack of regulation, 349 medication and foods interactions, 711–712 need for, 348–350, 353 non-nutrient, potential side effects, 712t protein, 230–232 use by athletes, 602 when to use, 349

surgery, weight loss, 566fig, 571fig sustainable food system, 761fig–764, 762t sweeteners, 140t synbiotics, 82–83 systolic pressure, 192, 718

T Table Tips

added sugars, subtracting, 136 balanced, varied, and moderate diet, 41 biotin, 375 breakfast, 677 calcium, 449 chromium, 489 copper, 480 digestion, improving, 97 drinking moderately, 271 energy levels, maintaining, 300 fiber intake, increasing, 129 fish, adding to diet, 193 folate, 381 food safety while traveling, 746 food waste, 786 gluten free, 100 hand washing, 741 healthy habits, 561 healthy heart, 195 iodine, 490 iron intake, 476 lactose intolerance, 116 magnesium, 453 nut intake, increasing, 195 older adults, healthy eating for, 710t pantothenic acid, 374 phosphorus and calcium, balancing, 451 potassium, 445 salt intake, reducing, 442 school lunches, 676 seafood safety, 738 selenium, 485 snacks during pregnancy, 635–636 toddler treats, 668

Index I-17

vitamin A, 335 vitamin B1, 365 vitamin B3, 371 vitamin B12, 384 vitamin B2, 368 vitamin B6, 377 vitamin C, 388 vitamin D, 339 vitamin E, 343 vitamin K, 347 vitamins, preserving, 326 water intake, 419 weight gain, healthy, 564 weight loss, 555 whole grains, 132 zinc, 483

tagalose, 140t target heart rate, 582–583 taste

food choices and, 4 zinc and, 482

TCA cycle, metabolic pathway, 298fig, 299t teens. See adolescents teeth

calcium and, 446 early-childhood caries, 647fig fluorapatite structure, 486fig mineralization, 436

temperature, body, regulation, 408fig temperature, cooking, 743–744fig, 744t temperature, environmental

basal metabolism and, 512t thermic effect of food, and, 513t

tertiary structure, protein, 210 thermic effect of food (TEF), 512–513fig thermogenesis, 513–514 thiamin (B1). See vitamin B1 thiamin pyrophosphate (TPP), 364, 365fig thirst center, 421, 424 thirst mechanism, 421, 424fig, 428 thyroxine-releasing hormone (TRH) , 490fig thyroxine-stimulating hormone (TSH) , 490fig thyroxine, 490fig time, food choices and, 6–7 tissue synthesis, 13 toddlers, 666. See also children, young Tolerable Upper Intake Level (UL), 46fig, 47, 48t tomatoes, as antioxidants, 329 tongue-thrust reflex, 650 tooth decay, early-childhood caries, 647fig total daily energy expenditure (TDEE)

calculation, 511–514 daily requirements, 511fig overview, 532fig

total iron-binding capacity (TIBC), 496 toxicity, 47

biotin, 375 calcium, 449 chloride, 443 chromium, 488 copper, 480 fluoride, 487 folate, 381 iron, 476–477 magnesium, 454 manganese, 493–494 minerals, 436–437t molybdenum, 492 pantothenic acid, 374

phosphorus, 452 potassium, 444–445 selenium, 485 sulfate, 455 trace minerals, 471t, 472 vitamin A, 334 vitamin B1, 365–366 vitamin B12, 385 vitamin B2, 368 vitamin B6, 378 vitamin C, 389 vitamin D, 339 vitamin E, 343–344 vitamin K, 346 vitamin, 320 vitamins, water-soluble, 363t zinc, 483

toxins, 732–738, 737fig trabecular bone, 446, 448fig trace minerals, 434, 435fig, 461fig, 498. See also

specific mineral names defined, 14 overview, 470–472, 471t

trans configuration, 162–163fig trans fats, 185–187. See also fat, dietary

heart disease and, 193 limiting, 50 percent Daily Values (%DVs), 61

transamination, 216–217fig, 299t transcription, 215fig, 216 transcobalamin, 382 transfer RNA (tRNA), 216 transferrin, 473 translation, 215fig, 216 transport. See also digestion

active, 92fig, 93, 106fig copper, 479 iron, 473–474fig lipids, , 169–171fig nutrients, 96–97, 107fig sodium, 438–439fig vitamin A, 330 vitamin D, 342 vitamin K, 345 water as medium for, 407 water-soluble vitamins, 360–361 zinc, 481

transport proteins, 219–220t traveler’s diarrhea, 746 trends, food choices and, 5–6 tricarboxylic acid (TCA) cycle, 288fig,

295–296fig, 312fig Trichinella spiralis, 734t triglycerides, 162–164, 163fig, 198fig

digestion, 167 insulation and protection from, 173 metabolism during feeding and fasting, 305t recommended daily intake, 175–178 storage, 302

trimesters, prenatal development, 620fig, 628fig, 655–656

tripeptide, 207 trivalent chromium, 488 tumor, 393 tumor suppressor genes, 393 twenty20-hour dietary recall, 20 type 1 diabetes, 142, 143fig. See also diabetes type 2 diabetes, 142, 143fig. See also diabetes

physical fitness and, 580t

vegetarian diet and, 236–237 childhood obesity and, 687 preventing, 147, 710t

Type I osteoporosis, 456 Type II osteoporosis, 456

U ulcer, 99fig ulcerative colitis, 104 umbilical cord, 621 underage drinking, 270 undernourished, 19 undernutrition. See also malnourished

chronic, 794t–795t disease and death from, 797fig undernourished, 19

underweight. See also disordered eating; malnour- ished

classified, 525t defined, 524–525t health risks, 539

unintentional food additives, 755 United States Pharmocopeia (USP) Verified

mark, 349fig universal solvent, water as, 407fig unsaturated fatty acid, 160fig upper esophageal sphincter, 78 urea, 97, 216 urinary incontinence, older adults, 707 urine color guide, 425fig USDA Food Safety and Inspection Service

(FSIS), 748t USDA Organic Seal, 760fig

V vaginal infections, beneficial bacteria, 83t vanadium, 494 varied diet, 40–41, 50 vasoconstrictor, 414 vegetables

calcium content, 449fig carbohydrate sources, 130fig, 132 children’s intake, 677t chromium sources, 489fig copper sources, 480fig energy density, 565fig fiber sources, 133fig folate sources, 381fig intake during pregnancy, 630fig iron sources, 476fig kilocalorie needs, 53t magnesium content, 453fig manganese sources, 493fig nutrient-rich, 52fig older adults, needs for, 703fig phosphorus content, 451fig potassium sources, 445fig protein and saturated fat, 233fig protein sources, 229fig selenium sources, 485fig sodium content, 441fig vegetarian diet, servings for, 238t vitamin A sources, 333fig vitamin B1 sources, 366fig vitamin B3 sources, 372fig vitamin B2 sources, 369fig vitamin B6 sources, 377fig vitamin C sources, 389fig

I-18 Index

vegetables (cont.) vitamin E content, 344fig vitamin K content, 347fig vitamins in, 325fig, 352fig washing, 742 water content, 419fig weight loss and, 553–554fig zinc sources, 482fig

vegetarian and vegan diet, 326–238t, 242 dos and don’ts, 236 My Vegan Plate, 237fig protein, adding, 239 supplements, use of, 349 young children on, 670–671

ventromedial nucleus, 541–542fig vertebrae, deterioration, 456fig very low-density lipoproteins (VLDLs),

169–170fig, 171fig villi, 79–80fig, 96fig, 107fig virus, 734–735. See also foodborne illness visceral fat, 519–520fig vision. See also blindness

age-related macular degeneration, 323fig 482 free radicals, damage by, 322–323 older adults, decline in, 701 older adults, eye disease in, 714 normal and impaired, 323fig retinal’s role, 331fig vitamin A and, 330

vitamin A. See also vitamins absorption and transport, 330 conversion of compounds, 329fig converting IUs, 333 daily needs, 332 deficiency, 334–335 food sources, 333 functions and sources, 327t healthy and deficient cells, 332fig metabolic functions, 330, 332 needs, 327t, 332 older adults, needs for, 707–708 overview, 328, 330, 352 pregnancy, intake during, 632 toxicity, 334 toxicity and deficiency, 327t vegetarian diet, 237

vitamin B, metabolic regulation, 284 vitamin B1. See also vitamins

beriberi, 361t, 366 as coenzyme, 13 daily needs, 365 food sources, 365 metabolism, 365fig overview, 364, 397fig sources and functions, 362t Wernicke-Korsakoff syndrome, 261

vitamin B2. See also vitamins daily needs, 368 food sources, 368, 369fig metabolic functions, 367–368fig overview, 366–367, 397fig sources and functions, 362t structures and coenzyme forms, 367fig toxicity and deficiency, 365–366, 368–369fig

vitamin B3. See also vitamins daily needs, 370–371 food sources, 371 metabolic function, 370, 371fig overview, 369–370, 398fig

sources and functions, 362t structure and coenzyme forms, 370fig toxicity and deficiency, 371–372fig

vitamin B6. See also vitamins daily needs, 377 food sources, 377 metabolic functions, 376 microcytic anemia and, 496, 501 morning sickness and, 632–633 overview, 376, 399fig sources and functions, 363t toxicity and deficiency, 378

vitamin B12. See also vitamins vegetarian diet and, 238 deficiency, 496–497 daily needs, 383–384 folate activation, 384fig food sources, 384 metabolic functions, 382–383 older adults, need for, 704t, 707–708 overview, 382, 399fig sources and functions, 363t toxicity and deficiency 385

vitamin C. See also vitamins common cold and, 390–391 daily needs, 388 food sources, 388–389fig metabolic functions, 387–388 overview, 387, 400fig sources and functions, 363t toxicity and deficiency, 389

vitamin D. See also vitamins adolescents, needs for, 682–683 babies and children, needs for, 349 chemical structure, 336fig daily needs, 338 deficiency, 339–342 food sources, 338, 339fig functions, needs, and sources, 327t metabolism, 336–337fig older adults, needs for, 704t, 707–708 overview, 335–336, 352 pregnancy recommendation, 631 relationship of blood calcium to parathyroid

hormone, 338fig, 352fig role of cholesterol, 174 toxicity and deficiency, 327t vegetarian diet and, 237–238 young children, needs for, 668, 670

vitamin E. See also vitamins absorption and transport, 342 daily needs, 343 deficiency, 344 food sources, 343 functions, needs, and sources, 327t metabolic functions, 342–343 overview, 342, 353fig toxicity, 343–344 toxicity and deficiency, 327t

vitamin K. See also vitamins absorption and transport, 345 daily needs, 346 food sources, 346 functions, needs, and sources, 327t metabolic functions, 345–346 overview, 345, 353fig toxicity and deficiency, 327t, 346–347

vitamins. See also B vitamins; fat-soluble vitamins; supplements; water-soluble vitamins;

specific vitamin names absorption and storage, 320–322 athletic performance and, 599,

601–602, 613 best sources, 324–326 bioavailability, 320–321 chemical composition, 9fig, 31fig classifications, 319 compounds similar to, 391–392, 400 fat-soluble, 14 food label information, 60fig fortified foods, 326 metabolic functions, 319t Nutrition Facts panel, 60fig overconsumption, 320 overview, 318–320, 351 vs. minerals, structure, 434fig pregnancy, nutrient needs, 630fig primary role, 12t, 13–14, 32 supplements, 348–350, 353

VO2max, 581

W waist circumference, 523, 526fig war, factor in global malnutrition, 785 wasting, 794 water. See also fluid balance

balance during exercise, maintaining, 422fig, 423

balance, maintaining, 409–414 blood pressure, effect on, 414–415fig, 427fig body composition, 406fig bottled vs. tap, 417–419 chemical composition, 9fig, 31fig daily needs, 416fig, 419, 427fig diuretics and, 420, 427 enhanced, 418 fluoride in, 486 intake and excretion, 410fig, 426fig, 427fig monitoring intake, 424–425 overconsumption, 421, 424–425 overview, 406–409, 426fig primary role, 12t, 14, 32 sources, 416fig, 419 sustainable food system, 763 underconsumption, 421, 424–425, 428.

See also dehydration; thirst mechanism as universal solvent, 407fig vitamins, effect on, 325

water intoxication, 421 water supply

improving sanitation, 792–793 safety, 751–752, 761fig sustainable system, 763

water-soluble vitamins, 351. See also specific vitamin names

absorption and storage, 321fig–322, 351fig categorizing, 319fig defined, 14 digestion and absorption, 360fig functions, needs, and sources, 362t overview, 360–361, 397 primary functions, 361 properties, 360–361 toxicity and deficiency, 362t

weight classifications, 525t energy balance and, 508

Index I-19

genetics and environment, 544–548, 550–551, 569

healthy, estimating, 523–526 hypertension and, 720 impact on bone mass, 458 low-birthweight, 624–625

weight gain. See also disordered eating; obesity; overweight

excessive alcohol consumption, 261, 263 pregnancy, 628–629fig, 629t

weight loss, 551–561. See also disordered eating; malnourished; underweight

maintaining, 563–564 medical interventions, 565–567 overview, 570 reasonable goals, 552–553 types of exercise, 558–560, 559fig

weight management, 195. See also energy balance vegetarian diet and, 237

behavior modification, overview, 570 carbohydrate-rich diet, 549–550 gaining weight healthfully, 564–565,

570 overview, 538–540, 568

Wernicke-Korsakoff syndrome, 261, 366 white fat, 519–520fig whole grains

as carbohydrate source, 131 as functional food, 16t

Wilson’s disease, 480 wine, 250t, 266 working poor, food insecurity and, 782

X X-ray, DEXA scan, 457fig xerophthalmia, 335 xylitol, 140t

Y young adults, college binge drinking, 270fig young children, dietary needs, 666–671

Z zinc

absorption, transport, and recycling, 481 common cold and, 390

daily needs, 482 food sources, 482fig–483 functions, needs, and sources, 471t intake during pregnancy, 631 metabolic functions, 481–482 older adults, needs for, 704t, 708–709 overview, 499fig toxicity and deficiency, 471t, 483

zoochemicals, 15 zygote, 620

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CR-1

Photo Credits Chapter 1 Chapter Opener: Darren Kemper/Corbis/Getty Images; p. 4: Karen Dreyer/Blend Images/Getty images; p. 5: Clive Streeter/Dorling Kindersley, Ltd.; Foodfolio/Alamy Stock Photo; Don Mason/Corbis Super/ Alamy Stock Photo; p. 6: Singkham/Shutterstock; Taylor S. Kennedy/National Geographic/Getty Images; p. 7: Mars Incorporated; p. 8: Michael Jung/Shut- terstock; A9photo/Shutterstock; Motorolka/Shutterstock; p. 10: Peter Bernik/ Shutterstock; p. 12: Darqué/Photocuisine/AGE Fotostock; p. 13: D. Hurst/ Alamy Stock Photo; p. 14: Purestock/Getty Images; p. 15: Don Smetzer/Alamy Stock Photo; p. 18: Tim Evans/Science Source; p. 20: Skynesher/E+/Getty Images; p. 24: Buena Vista Images/Digital Vision/Getty Images; Bill Aron/ PhotoEdit, Inc.; p. 25: Biophoto Associates/Science Source; p. 28: US Food and Drug Administration FDA; p. 29: Kristen Piljay/Pearson Education, Inc.; p. 31: Karen Dreyer/Blend Images/Getty images; p. 32: Don Smetzer/Alamy Stock Photo; Peter Bernik/Shutterstock; p. 33: Skynesher/E+/Getty Images; p. 34: US Food and Drug Administration FDA

Chapter 2 Chapter Opener: Agencja Free/Alamy Stock Photo; p. 40: William Shaw/Dorling Kindersley, Ltd.; p. 41: Jiri Hera/Fotolia; Jupiterimages/ Creatas/Getty Images; p. 42: Joe Gough/Shutterstock; p. 46: Samuel Borges/ Shutterstock; p. 50: Peter Cavanagh/Alamy Stock Photo; p. 55: Richard Megna/ Fundamental Photographs: NYC; p. 56: Radius Images/Alamy Stock Photo; Halfpoint/Shutterstock; p. 59: Guiding Stars Licensing Company; Pearson Edu- cation, Inc.; p. 60: B.A.E. Inc/Alamy Stock Photo; p. 62: Pearson Education, Inc.; p. 63: Sky Bonillo/PhotoEdit; p. 65: Kristen Piljay/Pearson Education, Inc.; p. 66: Kristen Piljay/Pearson Education, Inc.; p. 68: Radius Images/Alamy Stock Photo; p. 69: William Shaw/Dorling Kindersley, Ltd.; p. 70: Kristen Piljay/Pearson Education, Inc.

Chapter 3 Chapter Opener: Robert Deutschman/Palladium/AGE Fotos- tock; p. 76: Japack/AGE Fotostock; p. 77: Tom Grill/Corbis; p. 78: Wave- breakmedia/Shutterstock; p. 80: Maridav/Shutterstock; David Musher/Science Source; Steve Gschmeissner/Science Source; Don W Fawcett/Science Source; p. 82: Kristen Piljay/Pearson Education, Inc.; p. 84: Tom Grill/Corbis; p. 85: Tom Grill/Corbis; p. 86: Red Chopsticks/AGE Fotostock; p. 95: John Lund/ Blend Images/Corbis; p. 96: Joana Lopes/Shutterstock; p. 98: Images USA/ Alamy Stock Photo; p. 99: Dr. E. Walker/Science Source; Southern Illinois University/Science Source; p. 101: Koki Lino/Getty Images; p. 102: Cristovao/ Shutterstock; p. 103: Wavebreakmedia/Shutterstock; p. 104: David Musher/ Science Source; p. 105: Tom Grill/Corbis; p. 106: John Lund/Blend Images/ Corbis

Chapter 4 Chapter Opener: Newpi/E+/Getty Images; p. 115: Kristen Piljay/Pearson Education, Inc.; p. 117: Kristen Piljay/Pearson Education, Inc.; p. 118: Barbro Bergfeldt/Fotolia; p. 119: Food Collection/Getty Images; p. 121: Kostudio/Shutterstock; p. 123: Hongqi Zhang/123RF; p. 125: Yuri Acurs/Shutterstock; Flashon Studio/Shutterstock; p. 127: Comstock/Stock- byte/Getty Images; Dragon Fang/Shutterstock; p. 128: Elenathewise/Fotolia; p. 131: Zstock/Fotolia; p. 135: Pearson Education, Inc.; Ingram Publishing/ Alamy Stock Photo; James Benet/Getty Images; p. 136: Kristen Piljay/Pearson Education, Inc.; p. 137: Petro Perutsky/123RF; Rangizzz/123RF; p. 141: Pear- son Education, Inc.; p. 145: Dragon Images/Shutterstock; p. 146: Arka38/Shut- terstock; p. 147: Arek Malang/Shutterstock; p. 149: Yuri Acurs/Shutterstock; p. 150: Zstock/Fotolia; Pearson Education, Inc.; p. 151: Arka38/Shutterstock

Chapter 5 Chapter Opener: Creativ Studio Heinemann/Getty Images; p. 158: Ryan McVay/Photodisc/Getty Images; p. 162: Gemenacom/Fotolia;

p. 165: Charles Brutlag/Shutterstock; p. 166: Comstock Images/Stockbyte/ Getty Images; p. 172: Jose Luis Calvo/Shutterstock; p. 179: Shebeko/Shutt- terstock; p. 183: Geo Grafika/Alamy Stock Photo; p. 186: Brand X Pictures/ AGE Fotostock; p. 187: Dianne McFadden/Shutterstock; p. 188: Pearson Education, Inc.; p. 191: Eric Cohen/Biophoto Associates/Science Source; Pear- son Education, Inc.; p. 193: Ligia Botero/Photodisc/Getty Images; NF-05-12: Luchschen/123RF; p. 194: Pearson Education, Inc.; p. 195: Comstock/Stock- byte/Getty Images; p. 197: Wavebreak Media ltd/Alamy Stock Photo; p. 199: Shebeko/Shuttterstock; p. 200: Mariano Heluani/Shutterstock; Eric Cohen/ Biophoto Associates/Science Source

Chapter 6 Chapter Opener: Love_Life/E+/Getty Images; p. 206: Pidjoe/E+/Getty Images; p. 210: Riou/Photo Cuisine/Alamy Stock Photo; p. 214: Frederic Cirou/PhotoAlto/Alamy Stock Photo; p. 216: Pearson Edu- cation, Inc.; p. 219: Dr P. Marazzi/Science Source; p. 220: Juergen Berger/ Science Source; p. 212: John Lund/Tiffany Schoepp/Corbis; p. 222: Ruth Jenkinson/Dorling Kindersley, Ltd.; Monkey Business Images/ Shutterstock; Pearson Education, Inc.; p. 226: Macdaddy/Pearson Education, Inc.; p. 227: Dustin Dennis/ Shutterstock; p. 228: Stockstudios/Shutterstock; p. 229: Elena Elisseeva/Shutterstock; p. 231: Dolgachov/123RF; Svitlana Symonova/123RF; Maridav/123RF; p. 235: Dai Kurokawa/EPA/Newscom; Farah Abdi Warsameh/AP Images; p. 236: Elenathewise/Fotolia; p. 237: Cathy Yeulet/123RF; p. 239: Gun/Shutterstock; p. 241: Frederic Cirou/PhotoAlto/ Alamy Stock Photo; Monkey Business Images/Shutterstock; Elena Elisseeva/ Shutterstock; p. 242: Farah Abdi Warsameh/AP Images

Chapter 7 Chapter Opener: Shyripa Alexandr/Shutterstock; p. 250: Syracuse Newspapers/Jim Commentucci/The Image Works; p. 251: Pearson Education, Inc.; Yukata/Fotolia; p. 252: Foodcollection/Getty Images; John- foto18/Shutterstock; Pearson Education, Inc.; Rawpixel/Shutterstock; p. 253: Digital Vision/Getty Images; p. 254: Jim Varney/Science source; p. 257: Wavebreakmedia/Shutterstock; p. 258: Jack Dagley Photography/Shutterstock; p. 259: NF-07-06: Corbis/VCG/Getty Images; p. 260: Image Source/Corbis; p. 261: Richard Megna/Fundamental Photographs: NYC; p. 262: Antonio MP/ Getty Images; Peepo/Vetta/Getty Images; OlegSam/Shutterstock; Iofoto/ Shutterstock; Joy Brown/Shutterstock; npict/Fotolia; Danny Hooks/Fotolia; AmpFotoStudio.com/Fotolia; p. 264: Arthur Glauberman/Science Source; p. 265: Nd3000/Shutterstock; p. 266: Pearson Education, Inc.; p. 267: Ol_vic/ Shutterstock; p. 268: Pearson Education, Inc.; p. 271: Joe Koshellek/MCT/ Newscom; p. 273: Rawpixel/Shutterstock; Digital Vision/Getty Images; p. 274: Wavebreakmedia/Shutterstock; Image Source/Corbis; p. 275: Joe Koshellek/ MCT/Newscom

Chapter 8 Chapter Opener: Tom Grill/JGI/AGE Fotostock; p. 283: Bloomimage/Corbis; p. 290: Don Mason/Blend Images/Alamy Stock Photo; p. 295: ESB Professional/Shutterstock; p. 301: Rudchenko Liliia/Shutterstock; p. 303: Sniegirova Mariia/Shutterstock; April_89/Fotolia; p. 308: Chris Rout/ Alamy Stock Photo; p. 309: D.Hurst/Alamy Stock Photo; p. 310: Andy Dean Photography/Shutterstock; p. 312: Rudchenko Liliia/Shutterstock; p. 313: Andy Dean Photography/Shutterstock

Chapter 9 Chapter Opener: Burke’s Backyard/Alamy Stock Photo; p. 319: Mtsyri/Shutterstock; Stockbyte/Getty Images; p. 321: Best View Stock/ Alamy Stock Photo; p. 322: Dmytro Nikitin/123RF; p. 323: National Eye Institute; p. 326: A-plus image bank/Alamy Stock Photo; Pearson Education, Inc.; p. 328: Elena Schweitzer/Shutterstock; Sarsmis/Shutterstock; p. 329: Timmary/Shutterstock; p. 331: Siri Stafford/Digital Vision/Getty Images; p. 332: Suzanne Tucker/Shutterstock; p. 334: 09-11: James Stevenson/Science

Credits

CR-2 Credits

Source, p. 336: Gustoimages/Science Source, p. 337: Seth Joel/Photographer’s Choice/Getty Images, p. 338: John Smith/Photolibrary/Getty Images, p. 340: Pearson Education, Inc.; Jacek Chabraszewski/Fotolia; Biophoto Associates/ Science Source; p. 341: Arek Malang/Shutterstock; p. 342: Ian O’Leary/Dorling Kindersley, Ltd.; M.pilot/Shutterstock; p. 346: Scott Camazine/Alamy Stock Photo; p. 346: SPL/Science Source; p. 347 Suzifoo/Getty Images; p. 348: Kristin Piljay/Pearson Education, Inc.; Jupiterimages/Getty Images; p. 349: Registered trademark of The United States Pharmacopeial Convention. Used with Permission; p. 351: Mtsyri/Shutterstock, Stockbyte/Getty Images; p. 353: Kristin Piljay/Pearson Education, Inc.

Chapter 10 Chapter Opener: Lubos Chlubny/123RF; p. 364: Joe Gough/ Fotolia; p. 367: Ralph Morse//Time Life Pictures/Getty Images; Jjava/Foto- lia; p. 369: Biophoto Associates/Science Source; SPL/Science Source; p. 370: D.Hurst/Alamy Stock Photo; p. 372: Dr. M.A. Ansary/Science Source; p. 373: Smileus/Shutterstock; Justin Lightley/Photographer’s Choice/Getty Images; p. 374: Richard Semik/Shutterstock; p. 375: MaxPhotographer/Shutterstock; p. 376: FoodCollection/Photolibrary/Getty Images; Brand X Pictures/AGE Fotostock; p. 378: Tim Ridley/Dorling Kindersley, Ltd.; p. 380: Biophoto Associates/Science Source/Getty Images; p. 382: Olga Miltsova/Shutterstock; AmpFotoStudio/Shutterstock; p. 383: Pearson Education, Inc.; p. 384: Wave- breakmedia/Shutterstock; p. 386: Syda Productions/Shutterstock; p. 387: Pikselstock/Shutterstock; Brand X Pictures/AGE Fotostock; p. 388: SPL/ Science Source; p. 389: Pantakan Sakda/Shutterstock; p. 390: Jason Stitt/Shutter- stock; Antagain/E+/Getty Images; p. 394: Brand X Pictures/AGE Fotostock; p. 395: Brand X Pictures/AGE Fotostock; p. 400: AmpFotoStudio/Shutterstock

Chapter 11 Chapter Opener: Westend61/Getty Images; p. 406: Orange Line Media/Shutterstock; p. 407: Steve HIx/Fuse/Getty Images; p. 408: Dea/ L Ricciarini/De Agostini Editore/AGE Fotostock; Radius Images/Alamy Stock Photo; p. 410: Bit24/Fotolia; Odua Images/Fotolia; p. 412: TerryJ/E+/Getty Images; p. 416: Dave & Les Jacobs/Blend Images/Getty Images; p. 417: Wave Royalty Free/Design Pics Inc/Alamy Stock Photo; Dynamic Graphics Group/ Getty Images; p. 418: Pearson Education, Inc.; p. 420: Lucianne Pashley/Age Fotostock; p. 422: Sergey Peterman/Shutterstock; p. 422: George Dolgikh/Shut- terstock; Peter Bernik/Shutterstock; Jeremy Pembrey/Alamy Stock Photo; p. 424: Monika Wisniewska/Shutterstock; p. 427: Lucianne Pashley/Age Fotostock

Chapter 12 Chapter Opener: PhotoCuisine/Alamy Stock Photo; p. 435: Keko64/Shutterstock; p. 436: Eye of Science/Science Source; p. 440: Richard Megna/Fundamental Photographs, NYC; p. 442: Scott Thomas/Getty Images; p. 443: Nick Emm/Alamy Stock Photo; Joe Gough/Shutterstock; p. 444: Steve Sant/Alamy Stock Photo; p. 446: Smit/Shutterstock; Elena Schweitzer/Shut- terstock; Motorlka/Fotolia; p. 447: Buena Vista Images/Stone/Getty Images; p. 448: Lehner/E+/Getty Images; D.Hurst/Alamy Stock Photo; p. 449: Brand X Pictures/AGE Fotostock; p. 450: Nitr/Shutterstock; Michael Klein/Photo- library/Getty Images; p. 451: Vaivirga/Fotolia; p. 452: Ian O’Leary/Dorling Kindersley, Ltd.; p. 453: Dustin Dennis/Shutterstock; p. 454: Brand X Pictures/ Getty Images; p. 455: Larry Korb/Shutterstock; p. 456: United States Depart- ment of Health and Human Services; p. 457: Catherine Ursillo/Science Source; p. 458: Stockbyte/Getty Images; p. 460: Monkey Business Images/Shutterstock; p. 462: Steve Sant/Alamy Stock Photo; Smit/Shutterstock; Elena Schweitzer/ Shutterstock; Motorlka/Fotolia; Stockbyte/Getty Images; p. 463: Michael Klein/Photolibrary/Getty Images

Chapter 13 Chapter Opener: Elena Elisseeva/Alamy Stock Photo; p. 472: Olga Nayashkova/Shutterstock; p. 473: Steve Moss/Alamy Stock Photo; p. 476: C Squared Studios/Photodisc/Getty Images; p. 477: Dehooks/Getty Images; p. 478: Mimagephotography/Shutterstock; p. 479: Anna Sedneva/Getty Images; Foodcollection/Getty Images; p. 483: Jon Edwards Photography/Bon Appetit/Alamy Stock Photo; p. 483: Medical-on-Line/Alamy Stock Photo; p. 484: Olga Popova/Shutterstock; p. 486: Don Farrall/Getty Images; p. 487: 13-11: National Institute of Dental Research; John A Rizzo/Age Fotostock; p. 488: Hong Vo/Shutterstock; p. 490: Chatuphot/Shutterstock; Wavebreak- media/Shutterstock; p. 492: Marco Mayer/Shutterstock; Anna Hoychuk/Shut- terstock; Foodcollection/Getty Images; p. 493: Viktor/Fotolia; p. 495: Eric Grave/Science Source; Joaquin Carrillo Farga/Science Source; Ed Reschke/ Photolibrary/Getty Images; p. 496: Lostinbids/Getty Images; p. 497: Dani

Vincek/Fotolia; p. 498: FoodCollection/SuperStock; p. 500: National Institute of Dental Research; Foodcollection/StockFood GmbH/Alamy Stock Photo; Mike Goldwater/Alamy Stock Photo; Marco Mayer/Shutterstock; p. 501: Food- collection/Getty Images; p. 501: Anna Hoychuk/Shutterstock; Eric Grave/ Science Source; Joaquin Carrillo Farga/Science Source

Chapter 14 Chapter Opener: Erik Isakson/Tetra Images/Alamy Stock Photo; p. 509: Helder Almeida/Shutterstock; Kenneth Man/Shutterstock; Maga/Shutterstock; Light poet/Shutterstock; Zurijeta/Shutterstock; Brian A Jackson/Shutterstock; p. 513: NF-14-01: 2/Jack Hollingsworth/Ocean/Corbis; p. 514: Cultura Limited/SuperStock; p. 515: Timothy A. Clary/AFP/Getty Images/Newscom; p. 517: St Bartholomew’s Hospital/Science Source; Philippe Psaila/Science Source; p. 522: David Madison/Photographer’s Choice/Getty Images; Joe Traver/The LIFE Images Collection/Getty Images; Mauro Ferma- riello/Science Source; Pearson Education, Inc.; p. 523: Inmagine/Alamy Stock Photo; p. 526: Julien Warnand/EPA/Newscom; p. 527: Michaela Begsteiger/ Getty Images; p. 528: Barcroft Media/Getty Images; p. 529: Corbis/VCG/ Getty Images; p. 530: D. Hurst/Alamy Stock Photo; p. 532: St Bartholomew’s Hospital/Science Source; Mauro Fermariello/Science Source; p. 533: Corbis/ VCG/Getty Images

Chapter 15 Chapter Opener: JGI/Jamie Grill/Blend Images/Getty Images; p. 538: Bill Aron/PhotoEdit: Inc; p. 540: SilviaJansen/Vetta/Getty Images; p. 541: Laurence Mouton/PhotoAlto Sas/Alamy Stock Photo; p. 542: Dmitri Maruta/Alamy Stock Photo; p. 545: Ilene MacDonald/Alamy Stock Photo; p. 548: Inmagine Asia/AGE Fotostock; p. 549: Catalin Petolea/Shut- terstock; p. 551: ZUMA Press: Inc/Alamy Stock Photo; GlowImages/Alamy Stock Photo; p. 554: Department of Health and Human Services; p. 555: Bog- dan Wankowicz/Shutterstock; Photolibrary/Alamy Stock Photo; Foodcollection RF/Getty Images; p. 556: James Benet/Getty Images; p. 557: Ruth Jenkinson/ Dorling Kindersley, Ltd.; p. 558: William87/Fotolia; p. 562: Hoozone/Getty Images; p. 563: JGI/Blend Images/Getty Images; p. 566: Phanie/Alamy Stock Photo; p. 567: Peter Kramer/AP Images; p. 568: William87/Fotolia; Dmitri Maruta/Alamy Stock Photo; p. 569: Ilene MacDonald/Alamy Stock Photo; p. 570: Inmagine Asia/AGE Fotostock; Richard Megna/Fundamental Photo- graphs, NYC; Ruth Jenkinson/Dorling Kindersley, Ltd.

Chapter 16 Chapter Opener: Stock4B-RF/Getty Images; p. 578: Dan Dalton/Digital Vision/Getty Images; p. 580: BananaStock/Getty Images; Tamara Lackey/Getty Images; Arpad/Fotolia; Dex Image/Alamy Stock Photo; p. 581: Tetra Images/Getty Images; Ryan McVay/Photodisc/Getty Images; Stockbyte/Getty Images; Stockbyte/Getty Images; p. 582: Aletia2011/Fotolia; Sirtravelalot/Shutterstock; p. 589: Webphotographeer/Getty Images; p. 594: Peter Bernik/Shutterstock; Nigel Roddis/EPA/Newscom; Koji Aoki/Getty Images; Maho/Fotolia; Piluhin/Alamy Stock Photo; Maridav/Shutterstock; p. 596: Stockbroker/MBI/Alamy Stock Photo; p. 597: Elena Gaak/Shutter- stock; p. 598: Kristin Piljay/Pearson Education, Inc.; Kayte Deioma/PhotoEdit; p. 600: Skynesher/E+/Getty Images; p. 601: Duncan Selby/Alamy Stock Photo; p. 602: 101dalmatians/Getty Images; p. 604: John Giustina/Super- Stock/Corbis; p. 606: Siegi/Fotolia; p. 609: Kristin Piljay/Pearson Education, Inc.; p. 610: Kristin Piljay/Pearson Education, Inc.; p. 612: Dan Dalton/Digital Vision/Getty Images; p. 613: Elena Gaak/Shutterstock; Stockbroker/MBI/ Alamy Stock Photo; p. 614: Kristin Piljay/Pearson Education, Inc.

Chapter 17 Chapter Opener: Tetra Images/Brand X Pictures/Getty Images; p. 624: PictureIndia/Asia Images Group Pte Ltd/Alamy Stock Photo; p. 626: Dalaprod/Fotolia; p. 628: Andy Crawford/Dorling Kindersley, Ltd.; p. 632: Amarita/Shutterstock; p. 633: Shutterdandan/Shutterstock; p. 634: Freemixer/Getty Images; p. 635: Kristin Piljay/Pearson Education, Inc.; p. 636: Blend Images/SuperStock; p. 639: Erik Freeland/Corbis Historical/Getty Images; p. 641: Stewart Cohen/Blend Images/Getty Images; p. 643: It Stock Free/AGE Fotostock; p. 645: Sally and Richard Greenhill/Alamy Stock Photo; p. 647: Ted Croll/Science Source; p. 651: Mariusz S. Jurgielewicz/Shutterstock; p. 653: Serhiy Kobyakov/Shutterstock; p. 654: Kristin Piljay/Pearson Educa- tion, Inc.; p. 655: Blend Images/SuperStock; p. 656: Kristin Piljay/Pearson Education, Inc.; Erik Freeland/Corbis Historical/Getty Images; Andy Craw- ford/Dorling Kindersley, Ltd.; p. 657: Stewart Cohen/Blend Images/Getty Images; Mariusz S. Jurgielewicz/Shutterstock

Credits CR-3

Chapter 18 Chapter Opener: Werli Francois/Alamy Stock Images; p. 667: Simon Brown/Dorling Kindersley, Ltd.; p. 669: TF2/Picturesbyrob/ Alamy Stock Photo; p. 671: Ronnie Kaufman/Larry Hirshowitz/Blend Images/ Alamy Stock Photo; p. 672: Skip Nall/Alamy Stock Photo; p. 674: SB Profes- sional/Shutterstock; Wavebreak Media Ltd/123 RF; p. 677: Marnie Burkhart/ Fancy/Alamy Stock Photo; p. 679: Alin Dragulin/FogStock/Getty Images; Mike Booth/Alamy Stock Photo; p. 684: Oneinchpunch/Shutterstock; p. 686: Beyond/Kalle Singer/Micheko Productions Inh. Michele Vitucci/Alamy Stock Photo; p. 688: Digital Vision/Getty Images; p. 689: N. Aubrier/AGE Fotos- tock; Wavebreak Media Ltd/123 RF; p. 690: Oneinchpunch/Shutterstock; TF2/ Picturesbyrob/Alamy Stock Photo; Digital Vision/Getty Images

Chapter 19 Chapter Opener: Phanie/Alamy Stock Photo; p. 700: Blend Images/Ariel Skelley/Brand X Pictures/Getty Images; p. 701: SDA Ag. Research Center; SDA Ag. Research Center; p. 706: Chris Willson/Alamy Stock Photo; p. 708: Altrendo images/Getty Images; p. 711: Pinkcandy/Shut- terstock; p. 713: Sally and Richard Greenhill/Alamy Stock Photo; Fancy/Alamy Stock Photo; p. 715: Susan Chiang/Getty Images; p. 717: Tina Manley/Alamy Stock Photo; p. 719: WavebreakmediaMicro/Fotolia; Comstock/Getty Images; p. 720: Stockbyte/Getty Images; p. 721: Stevecoleimages/Getty Images; p. 723: SDA Ag. Research Center; Altrendo images/Getty Images; p. 724: Sally and Richard Greenhill/Alamy Stock Photo, Tina Manley/Alamy Stock Photo, WavebreakmediaMicro/Fotolia

Chapter 20 Chapter Opener: Lew Robertson/Corbis/Getty Images; p. 735: Phanie/Science Source; Cultura/REX/Shutterstock; p. 736: Eye of Science/Science Source; p. 740: Jacek Chabraszewski/Shutterstock; p. 742: Piga&catalano/Marka/AGE Fotostock; p. 743: United States Department of Agriculture; p. 747: Ruud Morijn/Fotolia; George Skene/MCT/Newscom; Andrew Rubtsov/Alamy Stock Photo; Paul Burns/Blend Images/Alamy Stock Photo; Monkey Business Images/Shutterstock; p. 749: Anke van Wyk/Shutter- stock; p. 751: Pearson Education, Inc.; p. 753: Africa Studio/Fotolia; p. 755: Gri- gorenko/Getty Images; p. 757: Sauletas/iStock/Getty Images; p. 763: Vovan/ Fotolia; p. 765: Dembinsky Photo Associates/Alamy Stock Photo; p. 766: Smi- leus/Shutterstock; p. 767: Michael Siluk/Alamy Stock Photo; Joel Nito/AFP/ Getty Images; p. 770: Cultura/REX/Shutterstock; Paul Burns/Blend Images/ Alamy Stock Photo; p. 771: Sauletas/iStock/Getty Images; Vovan/Fotolia

Chapter 21 Chapter Opener: Fstop123/Getty Images; p. 781: Jane Alex- ander/Photofusion Picture Library/Alamy Stock Photo; p. 783: David Gross- man/Alamy Stock Photo; p. 785: ESB Professional/Shutterstock; Lulu/Fotolia; p. 786: Mike Boyatt/Agstockusa/AGE Fotostock; p. 788: Mike Goldwater/ Alamy Stock Photo; p. 791: Susan Montoya Bryan/AP Images; Alain Evrard/ Robert Harding; p. 792: Boris Roessler/DPA/Picture-alliance/Newscom; p. 795: Jean-Marc Giboux/Getty Images; p. 796: Jane Alexander/Photofusion Picture Library/Alamy Stock Photo; ESB Professional/Shutterstock; Mike Goldwater/Alamy Stock Photo; p. 797: Susan Montoya Bryan/AP Images

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Infants 0–6 mo 0.7* 60* NDc 31* 4.4* 0.5* 9.1* 6–12 mo 0.8* 95* ND 30* 4.6* 0.5* 11.0

Children 1–3 y 1.3* 130 19* ND 7* 0.7* 13 4–8 y 1.7* 130 25* ND 10* 0.9* 19

Males 9–13 y 2.4* 130 31* ND 12* 1.2* 34 14–18 y 3.3* 130 38* ND 16* 1.6* 52 19–30 y 3.7* 130 38* ND 17* 1.6* 56 31–50 y 3.7* 130 38* ND 17* 1.6* 56 51–70 y 3.7* 130 30* ND 14* 1.6* 56 7 70 y 3.7* 130 30* ND 14* 1.6* 56

Females 9–13 y 2.1* 130 26* ND 10* 1.0* 34 14–18 y 2.3* 130 26* ND 11* 1.1* 46 19–30 y 2.7* 130 25* ND 12* 1.1* 46 31–50 y 2.7* 130 25* ND 12* 1.1* 46 51–70 y 2.7* 130 21* ND 11* 1.1* 46 7 70 y 2.7* 130 21* ND 11* 1.1* 46

Pregnancy 14–18 y 3.0* 175 28* ND 13* 1.4* 71 19–30 y 3.0* 175 28* ND 13* 1.4* 71 31–50 y 3.0* 175 28* ND 13* 1.4* 71

Lactation 14–18 y 3.8* 210 29* ND 13* 1.3* 71 19–30 y 3.8* 210 29* ND 13* 1.3* 71 31–50 y 3.8* 210 29* ND 13* 1.3* 71

Dietary Reference Intakes: RDA, AI* Total Water and Macronutrients

Note: This table (taken from the DRI reports, see www.nap.edu) presents Recommended Dietary Allowances (RDA) in bold type and Adequate Intakes (AI) in ordinary type followed by an aster- isk (*). An RDA is the average daily dietary intake level sufficient to meet the nutrient requirements of nearly all (97–98 percent) healthy individuals in a group. It is calculated from an Estimated Average Requirement (EAR). If sufficient scientific evidence is not available to establish an EAR, and thus calculate an RDA, an AI is usually developed. For healthy breast-fed infants, an AI is the mean intake. The AI for other life stage and gender groups is believed to cover the needs of all healthy individuals in the groups, but lack of data or uncertainty in the data prevent being able to specify with confidence the percentage of individuals covered by this intake. a Total water includes all water contained in food, beverages,

and drinking water.

b Based on g protein per kg of body weight for the reference body weight, e.g., for adults 0.8 g/kg body weight for the reference body weight.

c Not determined.

Data from: DIETARY REFERENCE INTAKES FOR ENERGY, CARBOHYDRATES, FIBER, FAT, FATTY ACIDS, CHOLES- TEROL, PROTEIN, AND AMINO ACIDS (MACRONUTRIENTS), National Academies Press. Copyright ©2002/2005 by the National Academy of Sciences. DIETARY REFERENCE INTAKES FOR WATER, POTASSIUM, SODIUM, CHLORIDE, AND SULFATE, National Academies Press. Copyright ©2005 by the National Academy of Sciences. These reports may be accessed via www.nap.edu. Courtesy of the National Acad- emies Press, Washington, DC. Reprinted with permission.

Daily Values for Food Labels* The Daily Values are standard values developed by the Food and Drug Administration (FDA) for use on food labels. The values are based on 2,000 kilocalories a day for adults and children over 4 years old.

Nutrient Amount Proteina 50 g Thiamin 1.5 mg Riboflavin 1.7 mg Niacin 20 mg NEb

Biotin 300 μg Pantothenic acid 10 mg Vitamin B6 2 mg Folate 400 μg Vitamin B12 6 μg Vitamin C 60 mg Vitamin A 5,000 IUc

Vitamin D 20 mg Vitamin E 30 IUc

Nutrient Amount Vitamin K 80 μg Calcium 1,300 mg Iron 18 mg Zinc 15 mg Iodine 150 μg Copper 2 mg Chromium 120 μg Selenium 70 μg Molybdenum 75 μg Manganese 2 mg Chloride 3,400 mg Magnesium 400 mg Phosphorus 1,000 mg

Food Component Amount Calculation Factors Fat 78 g 35% of kilocalories Saturated fat 20 g 10% of kilocalories Cholesterol 300 mg Same regardless of kilocalories Carbohydrate (total) 275 g 55% of kilocalories Fiber 28 g 11.5 g per 1,000 kilocalories Protein 50 g 10% of kilocalories Sodium 2,300 mg Same regardless of kilocalories Potassium 4,700 mg Same regardless of kilocalories

* Based on the proposed new Nutrition Facts Panel. a The Daily Values for protein vary for different groups: pregnant women, 60 g; nursing mothers, 65 g; infants

under 1 year, 14 g; children 1 to 4 years, 16 g. b Niacin equivalents. c Equivalent values for nutrients expressed as IU are: vitamin A, 1,500 retinol activity equivalents (RAE; assumes

a mix of 40% retinol and 60% beta-carotene); vitamin D, 10 μg; vitamin E, 20 mg.

Note: This table (taken from the DRI reports, see www.nap.edu) presents Recommended Dietary Allowances (RDAs) in bold type and Adequate Intakes (AIs) in ordinary type followed by an asterisk (*). An RDA is the aver- age daily dietary intake level sufficient to meet the nutrient requirements of nearly all (97–98 percent) healthy individuals in a group. It is calculated from an Estimated Average Requirement (EAR). If sufficient scientific evidence is not available to establish an EAR, and thus calculate an RDA, an AI is usu- ally developed. For healthy breast-fed infants, an AI is the mean intake. The AI for other life stage and gender groups is believed to cover the needs of all healthy individuals in the groups, but lack of data or uncertainty in the data prevent being able to specify with confidence the percentage of individuals covered by this intake.

Infants 0–6 mo 200* 0.2* 200* 0.01* 110* 0.27* 30* 0.003* 2* 100* 15* 2* 0.4* 0.12* 0.18*

6–12 mo 260* 5.5* 220* 0.5* 130* 11 75* 0.6* 3* 275* 20* 3 0.7* 0.37* 0.57*

Children 1–3 y 700 11* 340 0.7* 90 7 80 1.2* 17 460 20 3 3.0* 1.0* 1.5* 4–8 y 1,000 15* 440 1* 90 10 130 1.5* 22 500 30 5 3.8* 1.2* 1.9*

Males 9–13 y 1,300 25* 700 2* 120 8 240 1.9* 34 1,250 40 8 4.5* 1.5* 2.3* 14–18 y 1,300 35* 890 3* 150 11 410 2.2* 43 1,250 55 11 4.7* 1.5* 2.3* 19–30 y 1,000 35* 900 4* 150 8 400 2.3* 45 700 55 11 4.7* 1.5* 2.3* 31–50 y 1,000 35* 900 4* 150 8 420 2.3* 45 700 55 11 4.7* 1.5* 2.3* 51–70 y 1,000 30* 900 4* 150 8 420 2.3* 45 700 55 11 4.7* 1.3* 2.0* 7 70 y 1,200 30* 900 4* 150 8 420 2.3* 45 700 55 11 4.7* 1.2* 1.8*

Females 9–13 y 1,300 21* 700 2* 120 8 240 1.6* 34 1,250 40 8 4.5* 1.5* 2.3* 14–18 y 1,300 24* 890 3* 150 15 360 1.6* 43 1,250 55 9 4.7* 1.5* 2.3* 19–30 y 1,000 25* 900 3* 150 18 310 1.8* 45 700 55 8 4.7* 1.5* 2.3* 31–50 y 1,000 25* 900 3* 150 18 320 1.8* 45 700 55 8 4.7* 1.5* 2.3* 51–70 y 1,200 20* 900 3* 150 8 320 1.8* 45 700 55 8 4.7* 1.3* 2.0* 7 70 y 1,200 20* 900 3* 150 8 320 1.8* 45 700 55 8 4.7* 1.2* 1.8*

Pregnancy 14–18 y 1,300 29* 1,000 3* 220 27 400 2.0* 50 1,250 60 12 4.7* 1.5* 2.3* 19–30 y 1,000 30* 1,000 3* 220 27 350 2.0* 50 700 60 11 4.7* 1.5* 2.3* 31–50 y 1,000 30* 1,000 3* 220 27 360 2.0* 50 700 60 11 4.7* 1.5* 2.3*

Lactation 14–18 y 1,300 44* 1,300 3* 290 10 360 2.6* 50 1,250 70 13 5.1* 1.5* 2.3* 19–30 y 1,000 45* 1,300 3* 290 9 310 2.6* 50 700 70 12 5.1* 1.5* 2.3* 31–50 y 1,000 45* 1,300 3* 290 9 320 2.6* 50 700 70 12 5.1* 1.5* 2.3*

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Dietary Reference Intakes: RDA, AI* Elements

Data from: DIETARY REFERENCE INTAKES series, National Academies Press. Copyright ©1997, 1998, 2000, 2001, 2005, and 2011, by the National Academy of Sciences. These reports may be accessed via www.nap.edu. Courtesy of the National Academies Press, Washington, DC. Reprinted with permission.

Note: This table (taken from the DRI reports, see www.nap.edu) presents Recommended Dietary Allowances (RDAs) in bold type and Adequate Intakes (AIs) in ordinary type followed by an asterisk (*). An RDA is the aver- age daily dietary intake level sufficient to meet the nutrient requirements of nearly all (97–98 percent) healthy individuals in a group. It is calculated from an Estimated Average Requirement (EAR). If sufficient scientific evidence is not available to establish an EAR, and thus calculate an RDA, an AI is usu- ally developed. For healthy breast-fed infants, an AI is the mean intake. The AI for other life stage and gender groups is believed to cover the needs of all healthy individuals in the groups, but lack of data or uncertainty in the data prevent being able to specify with confidence the percentage of individuals covered by this intake.

a As retinol activity equivalents (RAEs). 1 RAE = 1 m g retinol, 12 μg β-carotene, 24 μg a-carotene, or 24 μg β-cryptoxanthin. The RAE for dietary provitamin A carotenoids is two-fold greater than retinol equivalents (RE), whereas the RAE for preformed vitamin A is the same as RE.

b As cholecalciferol. 1 μg cholecalciferol = 40 IU. vitamin D. c Under the assumption of minimal sunlight. d As α@tocopherol . α@Tocopherol includes RRR@α@tocopherol , the only

form of α@tocopherol that occurs naturally in foods, and the 2R-stereoiso- meric forms of α@tocopherol (RRR-, RSR-, RRS-, and RSS@α@tocopherol ) that occur in fortified foods and supplements. It does not include the 2S-stereoisomeric forms of α@tocopherol (SRR-, SSR-, SRS-, and SSS@α@tocopherol ), also found in fortified foods and supplements.

Infants 0–6 mo 400* 40* 10* 4* 2.0* 0.2* 0.3* 2* 0.1* 65* 0.4* 1.7* 5* 125* 6–12 mo 500* 50* 10* 5* 2.5* 0.3* 0.4* 4* 0.3* 80* 0.5* 1.8* 6* 150*

Children 1–3 y 300 15 15 6 30* 0.5 0.5 6 0.5 150 0.9 2* 8* 200* 4–8 y 400 25 15 7 55* 0.6 0.6 8 0.6 200 1.2 3* 12* 250*

Males 9–13 y 600 45 15 11 60* 0.9 0.9 12 1.0 300 1.8 4* 20* 375* 14–18 y 900 75 15 15 75* 1.2 1.3 16 1.3 400 2.4 5* 25* 550* 19–30 y 900 90 15 15 120* 1.2 1.3 16 1.3 400 2.4 5* 30* 550* 31–50 y 900 90 15 15 120* 1.2 1.3 16 1.3 400 2.4 5* 30* 550* 51–70 y 900 90 15 15 120* 1.2 1.3 16 1.7 400 2.4h 5* 30* 550* 7 70 y 900 90 20 15 120* 1.2 1.3 16 1.7 400 2.4h 5* 30* 550*

Females 9–13 y 600 45 15 11 60* 0.9 0.9 12 1.0 300 1.8 4* 20* 375* 14–18 y 700 65 15 15 75* 1.0 1.0 14 1.2 400i 2.4 5* 25* 400* 19–30 y 700 75 15 15 90* 1.1 1.1 14 1.3 400i 2.4 5* 30* 425* 31–50 y 700 75 15 15 90* 1.1 1.1 14 1.3 400i 2.4 5* 30* 425* 51–70 y 700 75 15 15 90* 1.1 1.1 14 1.5 400 2.4h 5* 30* 425* 7 70 y 700 75 20 15 90* 1.1 1.1 14 1.5 400 2.4h 5* 30* 425*

Pregnancy 14–18 y 750 80 15 15 75* 1.4 1.4 18 1.9 600j 2.6 6* 30* 450* 19–30 y 770 85 15 15 90* 1.4 1.4 18 1.9 600j 2.6 6* 30* 450* 31–50 y 770 85 15 15 90* 1.4 1.4 18 1.9 600j 2.6 6* 30* 450*

Lactation 14–18 y 1,200 115 15 19 75* 1.4 1.6 17 2.0 500 2.8 7* 35* 550* 19–30 y 1,300 120 15 19 90* 1.4 1.6 17 2.0 500 2.8 7* 35* 550* 31–50 y 1,300 120 15 19 90* 1.4 1.6 17 2.0 500 2.8 7* 35* 550*

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Dietary Reference Intakes: RDA, AI* Vitamins

e As niacin equivalents (NE). 1 mg of niacin = 60 mg of tryptophan; 0–6 months = preformed niacin (not NE).

f As dietary folate equivalents (DFE). 1 DFE = 1 μg food folate = 0.6 μg of folic acid from fortified food or as a supplement consumed with food = 0.5 μg of a supplement taken on an empty stomach.

g Although AIs have been set for choline, there are few data to assess whether a dietary supply of choline is needed at all stages of the life cycle, and it may be that the choline requirement can be met by endogenous syn- thesis at some of these stages.

h Because 10 to 30 percent of older people may malabsorb food-bound B12, it is advisable for those older than 50 years to meet their RDA mainly by consuming foods fortified with B12 or a supplement containing B12.

i In view of evidence linking folate intake with neural tube defects in the fetus, it is recommended that all women capable of becoming pregnant consume 400 μg from supplements or fortified foods in addition to intake of food folate from a varied diet.

j It is assumed that women will continue consuming 400 μg from supple- ments or fortified food until their pregnancy is confirmed and they enter prenatal care, which ordinarily occurs after the end of the periconceptional period—the critical time for formation of the neural tube.

Data from: DIETARY REFERENCE INTAKES series, National Academies Press. Copyright ©1997, 1998, 2000, 2001, 2005, and 2011, by the National Academy of Sciences. These reports may be accessed via www.nap.edu. Courtesy of the National Academies Press, Washington, DC. Reprinted with permission.

Note: A Tolerable Upper Intake Level (UL) is the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population. Unless otherwise specified, the UL represents total intake from food, water, and supple- ments. Due to a lack of suitable data, ULs could not be established for vitamin K, thiamin, riboflavin, vitamin B12, pantothenic acid, biotin, and carotenoids. In the absence of a UL, extra caution may be warranted in consuming levels above recommended intakes. Members of the general population should be advised not to routinely exceed the UL. The UL is not meant to apply to individuals who are treated with the nutrient under medical supervision or to individuals with predisposing conditions that modify their sensitivity to the nutrient.

a As preformed vitamin A only. b As α@tocopherol ; applies to any form of supplemental

α@tocopherol . c The ULs for vitamin E, niacin, and folate apply to synthetic

forms obtained from supplements, fortified foods, or a combination of the two.

d ND = Not determinable due to lack of data of adverse effects in this age group and concern with regard to lack of ability to handle excess amounts. Source of intake should be from food only to prevent high levels of intake.

Data from: DIETARY REFERENCE INTAKES series, National Academies Press. Copyright ©1997, 1998, 2000, 2001, and 2011, by the National Academy of Sciences. These reports may be accessed via www.nap.edu. Courtesy of the National Academies Press, Washington, DC. Reprinted with permission.

Vitamins

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Tolerable Upper Intake Levels (ULs)

Infants 0–6 mo 600 NDd 25 ND ND ND ND ND 6–12 mo 600 ND 38 ND ND ND ND ND

Children 1–3 y 600 400 63 200 10 30 300 1.0 4–8 y 900 650 75 300 15 40 400 1.0

Males 9–13 y 1,700 1,200 100 600 20 60 600 2.0 14–18 y 2,800 1,800 100 800 30 80 800 3.0 19–30 y 3,000 2,000 100 1,000 35 100 1,000 3.5 31–50 y 3,000 2,000 100 1,000 35 100 1,000 3.5 51–70 y 3,000 2,000 100 1,000 35 100 1,000 3.5 7 70 y 3,000 2,000 100 1,000 35 100 1,000 3.5

Females 9–13 y 1,700 1,200 100 600 20 60 600 2.0 14–18 y 2,800 1,800 100 800 30 80 800 3.0 19–30 y 3,000 2,000 100 1,000 35 100 1,000 3.5 31–50 y 3,000 2,000 100 1,000 35 100 1,000 3.5 51–70 y 3,000 2,000 100 1,000 35 100 1,000 3.5 7 70 y 3,000 2,000 100 1,000 35 100 1,000 3.5

Pregnancy 14–18 y 2,800 1,800 100 800 30 80 800 3.0 19–50 y 3,000 2,000 100 1,000 35 100 1,000 3.5

Lactation 14–18 y 2,800 1,800 100 800 30 80 800 3.0 19–50 y 3,000 2,000 100 1,000 35 100 1,000 3.5

Tolerable Upper Intake Levels (ULs)

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Elements

Note: A Tolerable Upper Intake Level (UL) is the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population. Unless otherwise specified, the UL represents total intake from food, water, and supplements. Due to a lack of suitable data, ULs could not be established for vitamin K, thiamin, riboflavin, vitamin B12, pantothenic acid, biotin, and carotenoids. In the absence of a UL, extra caution may be warranted in con- suming levels above recommended intakes. Members of the general population should be advised not to routinely exceed the UL. The UL is not meant to apply to individuals who are treated with the nutrient under medical supervision or to indi- viduals with predisposing conditions that modify their sensitivity to the nutrient.

d ND = Not determinable due to lack of data of adverse effects in this age group and concern with regard to lack of ability to handle excess amounts. Source of intake should be from food only to prevent high levels of intake.

e The ULs for magnesium represent intake from a pharmacological agent only and do not include intake from food and water.

f Although vanadium in food has not been shown to cause adverse effects in humans, there is no justification for adding vanadium to food, and vanadium supplements should be used with caution. The UL is based on adverse effects in laboratory animals, and this data could be used to set a UL for adults but not children and adolescents.

Data from: Reprinted with permission from the Dietary Reference Intakes series. Copyright 1997, 1998, 2000, 2001, 2005, 2011 by the National Academies of Sciences, courtesy of the National Academies Press, Washington, D.C. These reports may be accessed via www.nap.edu.

Infants 0–6 mo NDd 1,000 ND 0.7 ND 40 ND ND ND ND ND 45 ND 4 ND ND 6–12 mo ND 1,500 ND 0.9 ND 40 ND ND ND ND ND 60 ND 5 ND ND

Children 1–3 y 3 2,500 1,000 1.3 200 40 65 2 300 0.2 3 90 ND 7 1.5 2.3 4–8 y 6 2,500 3,000 2.2 300 40 110 3 600 0.3 3 150 ND 12 1.9 2.9

Males 9–13 y 11 3,000 5,000 10 600 40 350 6 1,100 0.6 4 280 ND 23 2.2 3.4 14–18 y 17 3,000 8,000 10 900 45 350 9 1,700 1.0 4 400 ND 34 2.3 3.6 19–30 y 20 2,500 10,000 10 1,100 45 350 11 2,000 1.0 4 400 1.8 40 2.3 3.6 31–50 y 20 2,500 10,000 10 1,100 45 350 11 2,000 1.0 4 400 1.8 40 2.3 3.6 51–70 y 20 2,000 10,000 10 1,100 45 350 11 2,000 1.0 4 400 1.8 40 2.3 3.6 7 70 y 20 2,000 10,000 10 1,100 45 350 11 2,000 1.0 3 400 1.8 40 2.3 3.6

Females 9–13 y 11 3,000 5,000 10 600 40 350 6 1,100 0.6 4 280 ND 23 2.2 3.4 14–18 y 17 3,000 8,000 10 900 45 350 9 1,700 1.0 4 400 ND 34 2.3 3.6 19–30 y 20 2,500 10,000 10 1,100 45 350 11 2,000 1.0 4 400 1.8 40 2.3 3.6 31–50 y 20 2,500 10,000 10 1,100 45 350 11 2,000 1.0 4 400 1.8 40 2.3 3.6 51–70 y 20 2,000 10,000 10 1,100 45 350 11 2,000 1.0 4 400 1.8 40 2.3 3.6 7 70 y 20 2,000 10,000 10 1,100 45 350 11 2,000 1.0 3 400 1.8 40 2.3 3.6

Pregnancy 14–18 y 17 3,000 8,000 10 900 45 350 9 1,700 1.0 3.5 400 ND 34 2.3 3.6 19–50 y 20 2,500 10,000 10 1,100 45 350 11 2,000 1.0 3.5 400 ND 40 2.3 3.6

Lactation 14–18 y 17 3,000 8,000 10 900 45 350 9 1,700 1.0 4 400 ND 34 2.3 3.6 19–50 y 20 2,500 10,000 10 1,100 45 350 11 2,000 1.0 4 400 ND 40 2.3 3.6