Human nutrition

Human nutrition is the provision to obtain the essential nutrients necessary to support life and health. In general, people can survive for two to eight weeks without food, depending on stored body fat and muscle mass.^{[citation needed]}

Poor nutrition is a chronic problem linked to poverty, poor nutrition understanding and practices, and deficient sanitation and food security.^[1] Malnutrition globally provides many challenges to individuals and societies. Lack of proper nutrition contributes to worse class performance, lower test scores, and eventually less successful students and a less productive and competitive economy.^[2] Malnutrition and its consequences are immense contributors to deaths and disabilities worldwide.^[2] Promoting good nutrition helps children grow, promotes human development and advances economic growth and eradication of poverty.^[1]

Overview

Nutritional science investigates the metabolic and physiological responses of the body to diet. With advances in the fields of molecular biology, biochemistry, genetics, the study of nutrition is increasingly concerned with metabolism and metabolic pathways: the sequences of biochemical steps through which substances in living things change from one form to another.

The human body contains chemical compounds, such as water, carbohydrates (sugar, starch, and fiber), amino acids (in proteins), fatty acids (in lipids), and nucleic acids (DNA and RNA). These compounds in turn consist of elements such as carbon, hydrogen, oxygen, nitrogen, phosphorus, calcium, iron, zinc, magnesium, manganese, and so on. All of these chemical compounds and elements occur in various forms and combinations (e.g. hormones, vitamins, phospholipids, hydroxyapatite), both in the human body and in the plant and animal organisms that humans eat.

Studies of nutritional status must take into account the state of the body before and after experiments, as well as the chemical composition of the whole diet and of all material excreted and eliminated from the body (in urine and feces). Comparing the food to the waste can help determine the specific compounds and elements absorbed and metabolized in the body. The effects of nutrients may only be discernible over an extended period, during which all food and waste must be analyzed. The number of variables involved in such experiments is high, making nutritional studies time-consuming and expensive, which explains why the science of human nutrition is still slowly evolving.

Nutrients

There are seven major classes of nutrients: carbohydrates, fats, dietary fiber, minerals, proteins, vitamins, and water.

These nutrient classes can be categorized as either macronutrients (needed in relatively large amounts) or micronutrients (needed in smaller quantities). The macronutrients are carbohydrates, fats, fiber, proteins, and water. The micronutrients are minerals and vitamins.

The macronutrients (excluding fiber and water) provide structural material (amino acids from which proteins are built, and lipids from which cell membranes and some signaling molecules are built), energy. Some of the structural material can be used to generate energy internally, and in either case it is measured Joules or kilocalories (often called "Calories" and written with a capital C to distinguish them from little 'c' calories). Carbohydrates and proteins provide 17 kJ approximately (4 kcal) of energy per gram, while fats provide 37 kJ (9 kcal) per gram,^[3] though the net energy from either depends on such factors as absorption and digestive effort, which vary substantially from instance to instance. Vitamins, minerals, fiber, and water do not provide energy, but are required for other reasons. A third class of dietary material, fiber (i.e., non-digestible material such as cellulose), seems also to be required, for both mechanical and biochemical reasons, though the exact reasons remain unclear.

Molecules of carbohydrates and fats consist of carbon, hydrogen, and oxygen atoms. Carbohydrates range from simple monosaccharides (glucose, fructose, galactose) to complex polysaccharides (starch). Fats are triglycerides, made of assorted fatty acid monomers bound to a glycerol backbone. Some fatty acids, but not all, are essential in the diet: they cannot be synthesized in the body. Protein molecules contain nitrogen atoms in addition to carbon, oxygen, and hydrogen. The fundamental components of protein are nitrogen-containing amino acids, some of which are essential in the sense that humans cannot make them internally. Some of the amino acids are convertible (with the expenditure of energy) to glucose and can be used for energy production just as ordinary glucose. By breaking down existing protein, some glucose can be produced internally; the remaining amino acids are discarded, primarily as urea in urine. This occurs naturally when atrophy takes place, or during periods of starvation.

Other micronutrients include antioxidants and phytochemicals which are said to influence (or protect) some body systems. Their necessity is not as well established as in the case of, for instance, vitamins.

Most foods contain a mix of some or all of the nutrient classes, together with other substances. Some nutrients can be stored internally (e.g., the fat soluble vitamins), while others are required more or less continuously. Poor health can be caused by a lack of required nutrients or, in extreme cases, too much of a required nutrient. For example, both salt and water (both absolutely required) will cause illness or even death in too large amounts.

Carbohydrates

Carbohydrates may be classified as monosaccharides, disaccharides, or polysaccharides depending on the number of monomer (sugar) units they contain. They constitute a large part of foods such as rice, noodles, bread, and other grain-based products.

Monosaccharides contain one sugar unit, disaccharides two, and polysaccharides three or more. Polysaccharides are often referred to as complex carbohydrates because they are typically long multiple branched chains of sugar units. The difference is that complex carbohydrates take longer to digest and absorb since their sugar units must be separated from the chain before absorption. The spike in blood glucose levels after ingestion of simple sugars is thought to be related to some of the heart and vascular diseases which have become more frequent in recent times. Simple sugars form a greater part of modern diets than formerly, perhaps leading to more cardiovascular disease. The degree of causation is still not clear, however.

Simple carbohydrates are absorbed quickly, and therefore raise blood-sugar levels more rapidly than other nutrients. However, the most important plant carbohydrate nutrient, starch, varies in its absorption. Gelatinized starch (starch heated for a few minutes in the presence of water) is far more digestible than plain starch. And starch which has been divided into fine particles is also more absorbable during digestion. The increased effort and decreased availability reduces the available energy from starchy foods substantially and can be seen experimentally in rats and anecdotally in humans. Additionally, up to a third of dietary starch may be unavailable due to mechanical or chemical difficulty.

Fat

A molecule of dietary fat typically consists of several fatty acids (containing long chains of carbon and hydrogen atoms), bonded to a glycerol. They are typically found as triglycerides (three fatty acids attached to one glycerol backbone). Fats may be classified as saturated or unsaturated depending on the detailed structure of the fatty acids involved.^{[citation needed]} Saturated fats have all of the carbon atoms in their fatty acid chains bonded to hydrogen atoms, whereas unsaturated fats have some of these carbon atoms double-bonded, so their molecules have relatively fewer hydrogen atoms than a saturated fatty acid of the same length. Unsaturated fats may be further classified as monounsaturated (one double-bond) or polyunsaturated (many double-bonds). Furthermore, depending on the location of the double-bond in the fatty acid chain, unsaturated fatty acids are classified as omega-3 or omega-6 fatty acids. Trans fats are a type of unsaturated fat with trans-isomer bonds; these are rare in nature and in foods from natural sources; they are typically created in an industrial process called (partial) hydrogenation.

Many studies have shown that unsaturated fats, particularly monounsaturated fats, are best in the human diet. Saturated fats, typically from animal sources, are next, while trans fats are to be avoided. Saturated and some trans fats are typically solid at room temperature (such as butter or lard), while unsaturated fats are typically liquids (such as olive oil or flaxseed oil). Trans fats are very rare in nature, but have properties useful in the food processing industry, such as rancidity resistance.^{[citation needed]}

Most fatty acids are non-essential, meaning the body can produce them as needed, generally from other fatty acids and always by expending energy to do so. However, in humans at least two fatty acids are essential and must be included in the diet. An appropriate balance of essential fatty acids – omega-3 and omega-6 fatty acids – seems also important for health, though definitive experimental demonstration has been elusive. Both of these "omega" long-chain polyunsaturated fatty acids are substrates for a class of eicosanoids known as prostaglandins, which have roles throughout the human body. They are hormones, in some respects. The omega-3 eicosapentaenoic acid (EPA), which can be made in the human body from the omega-3 essential fatty acid alpha-linolenic acid (LNA), or taken in through marine food sources, serves as a building block for series 3 prostaglandins (e.g. weakly inflammatory PGE3). The omega-6 dihomo-gamma-linolenic acid (DGLA) serves as a building block for series 1 prostaglandins (e.g. anti-inflammatory PGE1), whereas arachidonic acid (AA) serves as a building block for series 2 prostaglandins (e.g., pro-inflammatory PGE 2). Both DGLA and AA can be made from the omega-6 linoleic acid (LA) in the human body, or can be taken in directly through food. An appropriately balanced intake of omega-3 and omega-6 partly determines the relative production of different prostaglandins: one reason a balance between omega-3 and omega-6 is believed important for cardiovascular health. In industrialized societies, people typically consume large amounts of processed vegetable oils, which have reduced amounts of the essential fatty acids along with too much of omega-6 fatty acids relative to omega-3 fatty acids.

Fiber

Dietary fiber is a carbohydrate (or a polysaccharide) that is incompletely absorbed in humans and in some animals. Like all carbohydrates, when it is metabolized it can produce four calories (kilocalories) of energy per gram. But in most circumstances it accounts for less than that because of its limited absorption and digestibility. There are two subcategories: insoluble and soluble fiber. Insoluble dietary fiber consists mainly of cellulose, a large carbohydrate polymer that is indigestible by humans who do not have the required enzymes to disassemble it nor do their digestive systems harbor sufficient quantities of the types of microbes that can do so either. Soluble dietary fiber comprises a variety of oligosaccharides, waxes, esters, resistant starches and other carbohydrates that dissolve or gelatinize in water. Many of these soluble fibers can be fermented or partially fermented by microbes in the human digestive system to produce short-chain fatty acids which are absorbed and therefore introduce some caloric content.

Whole grains, beans and other legumes, fruits (especially plums, prunes, and figs), and vegetables are good sources of dietary fiber. Fiber is important to digestive health and is thought to reduce the risk of colon cancer.^{[citation needed]} For mechanical reasons it can help in alleviating both constipation and diarrhea. Fiber provides bulk to the intestinal contents, and insoluble fiber especially stimulates peristalsis – the rhythmic muscular contractions of the intestines which move digesta along the digestive tract. Some soluble fibers produce a solution of high viscosity; this is essentially a gel, which slows the movement of food through the intestines. Additionally, fiber, perhaps especially that from whole grains, may help lessen insulin spikes and reduce the risk of type 2 diabetes.^{[citation needed]}

Protein

Proteins are the basis of many animal body structures (e.g. muscles, skin, and hair). They also form the enyzmes which catalyse chemical reactions throughout the body. Each molecule is composed of amino acids which are characterized by containing nitrogen and sometimes sulphur (these components are responsible for the distinctive smell of burning protein, such as the keratin in hair). The body requires amino acids to produce new proteins (protein retention) and to replace damaged proteins (maintenance). Amino acids are soluble in the digestive juices within the small intestine, where they are absorbed into the blood. Once absorbed they cannot be stored in the body, so they are either metabolised as required or excreted in the urine.

For all animals, some amino acids are essential (an animal cannot produce them internally) and some are non-essential (the animal can produce them from other amino acids). Twenty two amino acids can be found in the human body, and about ten of these are essential, and therefore must be included in the diet. A diet that contains adequate amounts of amino acids (especially those that are essential) is particularly important in some situations: during early development and maturation, pregnancy, lactation, or injury (a burn, for instance). A complete protein source contains all the essential amino acids; an incomplete protein source lacks one or more of the essential amino acids.

It is a common misconception that a vegetarian diet will be insufficient in essential proteins; both vegetarians and vegans of any age and gender, with a healthy diet, can flourish throughout all stages of life, although the latter group typically need to pay more attention to their nutrition than the former.

Minerals

Dietary minerals are the chemical elements required by living organisms, other than the four elements carbon, hydrogen, nitrogen, and oxygen that are present in nearly all organic molecules. The term "mineral" is archaic, since the intent is to describe simply the less common elements in the diet. Some are heavier than the four just mentioned – including several metals, which often occur as ions in the body. Some dietitians recommend that these be supplied from foods in which they occur naturally, or at least as complex compounds, or sometimes even from natural inorganic sources (such as calcium carbonate from ground oyster shells). Some are absorbed much more readily in the ionic forms found in such sources. On the other hand, minerals are often artificially added to the diet as supplements; the most famous is likely iodine in iodized salt which prevents goiter.

Essential dietary minerals

• Chlorine as chloride ions; very common electrolyte; see sodium, below
• Magnesium, required for processing ATP and related reactions (builds bone, causes strong peristalsis, increases flexibility, increases alkalinity). Approximately 50% is in bone, the remaining 50% is almost all inside body cells, with only about 1% located in extracellular fluid. Food sources include oats, buckwheat, tofu, nuts, caviar, green leafy vegetables, legumes, and chocolate.^[4][5]
• Phosphorus, required component of bones; essential for energy processing^[6] Approximately 80% is found in inorganic portion of bones and teeth. Phosphorus is a component of every cell, as well as important metabolites, including DNA, RNA, ATP, and phospholipids. Also important in pH regulation. Food sources include cheese, egg yolk, milk, meat, fish, poultry, whole-grain cereals, and many others.^[4]
• Potassium, a very common electrolyte (heart and nerve health). With sodium, potassium is involved in maintaining normal water balance, osmotic equilibrium, and acid-base balance. In addition to calcium, it is important in the regulation of neuromuscular activity. Food sources include bananas, avocados, vegetables, potatoes, legumes, and mushrooms.^[5]
• Sodium, a very common electrolyte; not generally found in dietary supplements, despite being needed in large quantities, because the ion is very common in food: typically as sodium chloride, or common salt

Trace minerals

Many elements are required in smaller amounts (microgram quantities), usually because they play a catalytic role in enzymes.^[7] Some trace mineral elements (RDA < 200 mg/day) are, in alphabetical order:

• Cobalt required for biosynthesis of vitamin B₁₂ family of coenzymes
• Copper required component of many redox enzymes, including cytochrome c oxidase
• Chromium required for sugar metabolism
• Iodine required not only for the biosynthesis of thyroxin, but probably, for other important organs as breast, stomach, salivary glands, thymus etc. (see Extrathyroidal iodine); for this reason iodine is needed in larger quantities than others in this list, and sometimes classified with the macrominerals
• Iron required for many enzymes, and for hemoglobin and some other proteins
• Manganese (processing of oxygen)
• Molybdenum required for xanthine oxidase and related oxidases
• Nickel present in urease
• Selenium required for peroxidase (antioxidant proteins)
• Zinc required for several enzymes such as carboxypeptidase, liver alcohol dehydrogenase, carbonic anhydrase

Vitamins

As with the minerals discussed above, some vitamins are recognized as essential nutrients, necessary in the diet for good health. (Vitamin D is the exception: it can alternatively be synthesized in the skin, in the presence of UVB radiation.) Certain vitamin-like compounds that are recommended in the diet, such as carnitine, are thought useful for survival and health, but these are not "essential" dietary nutrients because the human body has some capacity to produce them from other compounds. Moreover, thousands of different phytochemicals have recently been discovered in food (particularly in fresh vegetables), which may have desirable properties including antioxidant activity (see below); experimental demonstration has been suggestive but inconclusive. Other essential nutrients not classed as vitamins include essential amino acids (see above), choline, essential fatty acids (see above), and the minerals discussed in the preceding section.

Vitamin deficiencies may result in disease conditions: goiter, scurvy, osteoporosis, impaired immune system, disorders of cell metabolism, certain forms of cancer, symptoms of premature aging, and poor psychological health (including eating disorders), among many others.^[8] Excess of some vitamins is also dangerous to health (notably vitamin A), and for at least one vitamin, B6, toxicity begins at levels not far above the required amount. Deficiency or excess of minerals can also have serious health consequences.

For those who have healthy kidneys, it is somewhat difficult to drink too much water,^{[citation needed]} but (especially in warm humid weather and while exercising) it is dangerous to drink too little. People can drink far more water than necessary while exercising, however, putting them at risk of water intoxication, which can be fatal. In particular, large amounts of de-ionized water are dangerous.

There is research interest in the health effects of phytochemicals, but to date there is no conclusive evidence.^[9] While many fruits and vegetables which happen to contain phytochemicals are thought to be components of a healthy diet, by comparison dietary supplements based on them have no proven health benefit.^[9]

Nutrition for Special Populations

Sports nutrition

Individuals with highly active lifestyles require more nutrients.

Protein

Protein is an important component of every cell in the body. Hair and nails are mostly made of protein. The body uses protein to build and repair tissues. Also protein is used to make enzymes, hormones, and other body chemicals. Protein is an important building block of bones, muscles, cartilage, skin, and blood.

The protein requirement for each individual differs, as do opinions about whether and to what extent physically active people require more protein. The 2005 Recommended Dietary Allowances (RDA), aimed at the general healthy adult population, provide for an intake of 0.8 – 1 grams of protein per kilogram of body weight (according to the BMI formula), with the review panel stating that "no additional dietary protein is suggested for healthy adults undertaking resistance or endurance exercise".^[10] Conversely, Di Pasquale (2008), citing recent studies, recommends a minimum protein intake of 2.2 g/kg "for anyone involved in competitive or intense recreational sports who wants to maximize lean body mass but does not wish to gain weight".^[11]

Water and salts

Water is one of the most important nutrients in the sports diet. It helps eliminate food waste products in the body, regulates body temperature during activity and helps with digestion. Maintaining hydration during periods of physical exertion is key to peak performance. While drinking too much water during activities can lead to physical discomfort, dehydration in excess of 2% of body mass (by weight) markedly hinders athletic performance.^[12] Water and salt dosage is based on work performed, lean body mass, and environmental factors, especially ambient temperature and humidity. Maintaining the right amount is key.

Additional carbohydrates and protein taken before, during, and after exercise will improve endurance (increase time to exhaustion) as well as speed recovery as long as the exercise is compatible with digestion of the substance taken, e.g. a steak eaten while running a marathon may not be fully digested and may hinder performance.

Carbohydrates

The main fuel used by the body during exercise is carbohydrates, which is stored in muscle as glycogen – a form of sugar. During exercise, muscle glycogen reserves can be used up, especially when activities last longer than 90 min.^{[citation needed]} Because the amount of glycogen stored in the body is limited, it is important for athletes to replace glycogen by consuming a diet high in carbohydrates. Meeting energy needs can help improve performance during the sport, as well as improve overall strength and endurance.

There are different kinds of carbohydrates: simple (for example from fruits) and complex (for example from grains such as wheat). Simple sugars can be from an unrefined natural source, or may be refined and added to processed food. A typical American consumes about 50% of their carbohydrates as refined sugars. Over the course of a year, the average American consumes 204 litres (54 US gallons @ 3.78l per gallon) of soft drinks, which contain the highest amount of added sugars.^[13] Even though carbohydrates are necessary for humans to function, they are not all equally healthful. When machinery has been used to remove bits of high fiber, the carbohydrates are refined. These are the carbohydrates found in white bread and fast food.^[14]

Child and Maternal Nutrition

Elderly Nutrition

Malnutrition

Malnutrition refers to insufficient, excessive, or imbalanced consumption of nutrients. In developed countries, the diseases of malnutrition are most often associated with nutritional imbalances or excessive consumption. Although there are more people in the world who are malnourished due to excessive consumption, according to the United Nations World Health Organization, the real challenge in developing nations today, more than starvation, is combating insufficient nutrition – the lack of nutrients necessary for the growth and maintenance of vital functions.

The causes of malnutrition are directly linked to inadequate macronutrient consumption and disease, and are indirectly linked to factors like “household food security, maternal and child care, health services, and the environment.” ^[2]

Individual nutrition challenges

Illnesses

Nutrients	Deficiency	Excess
Energy	starvation, marasmus	obesity, diabetes mellitus, cardiovascular disease
Simple carbohydrates	none	diabetes mellitus, obesity
Complex carbohydrates	none	obesity
Saturated fat	low sex hormone levels [15]	cardiovascular disease[citation needed]
Trans fat	none	cardiovascular disease
Unsaturated fat	none	obesity
Fat	malabsorption of fat-soluble vitamins, rabbit starvation (if protein intake is high), during development: stunted brain development and reduced brain weight.[16]	cardiovascular disease[citation needed]
Omega-3 fats	cardiovascular disease	bleeding, hemorrhages
Omega-6 fats	none	cardiovascular disease, cancer
Cholesterol	during development: deficiencies in myelinization of the brain.[17]	cardiovascular disease[citation needed]
Protein	kwashiorkor
Sodium	hyponatremia	hypernatremia, hypertension
Iron	anemia	cirrhosis, cardiovascular disease
Iodine	goiter, hypothyroidism	Iodine toxicity (goiter, hypothyroidism)
Vitamin A	xerophthalmia and night blindness, low testosterone levels	hypervitaminosis A (cirrhosis, hair loss)
Vitamin B1	beriberi
Vitamin B2	cracking of skin and corneal unclearation
Niacin	pellagra	dyspepsia, cardiac arrhythmias, birth defects
Vitamin B12	pernicious anemia
Vitamin C	scurvy	diarrhea causing dehydration
Vitamin D	rickets	hypervitaminosis D (dehydration, vomiting, constipation)
Vitamin E	nervous disorders	hypervitaminosis E (anticoagulant: excessive bleeding)
Vitamin K	hemorrhage
Calcium	osteoporosis, tetany, carpopedal spasm, laryngospasm, cardiac arrhythmias	fatigue, depression, confusion, anorexia, nausea, vomiting, constipation, pancreatitis, increased urination
Magnesium	hypertension	weakness, nausea, vomiting, impaired breathing, and hypotension
Potassium	hypokalemia, cardiac arrhythmias	hyperkalemia, palpitations

Mental agility

Research indicates that improving the awareness of nutritious meal choices and establishing long-term habits of healthy eating has a positive effect on a cognitive and spatial memory capacity, potentially increasing a student's potential to process and retain academic information. ^{[citation needed]}

Some organizations have begun working with teachers, policymakers, and managed foodservice contractors to mandate improved nutritional content and increased nutritional resources in school cafeterias from primary to university level institutions. Health and nutrition have been proven to have close links with overall educational success.^[18] Currently less than 10% of American college students report that they eat the recommended five servings of fruit and vegetables daily.^[19] Better nutrition has been shown to have an impact on both cognitive and spatial memory performance; a study showed those with higher blood sugar levels performed better on certain memory tests.^[20] In another study, those who consumed yogurt performed better on thinking tasks when compared to those who consumed caffeine free diet soda or confections.^[21] Nutritional deficiencies have been shown to have a negative effect on learning behavior in mice as far back as 1951.^[22]

"Better learning performance is associated with diet induced effects on learning and memory ability".^[23]

The "nutrition-learning nexus" demonstrates the correlation between diet and learning and has application in a higher education setting.

"We find that better nourished children perform significantly better in school, partly because they enter school earlier and thus have more time to learn but mostly because of greater learning productivity per year of schooling."^[24]

91% of college students feel that they are in good health while only 7% eat their recommended daily allowance of fruits and vegetables.^[19]

Nutritional education is an effective and workable model in a higher education setting.^[24][25]

More "engaged" learning models that encompass nutrition is an idea that is picking up steam at all levels of the learning cycle.^[26]

There is limited research available that directly links a student's Grade Point Average (G.P.A.) to their overall nutritional health. Additional substantive data is needed to prove that overall intellectual health is closely linked to a person's diet, rather than a correlation fallacy.

Mental disorders

Nutritional supplement treatment may be appropriate for major depression, bipolar disorder, schizophrenia, and obsessive compulsive disorder, the four most common mental disorders in developed countries.^[27] Supplements that have been studied most for mood elevation and stabilization include eicosapentaenoic acid and docosahexaenoic acid (each of which are an omega-3 fatty acid contained in fish oil, but not in flaxseed oil), vitamin B₁₂, folic acid, and inositol.

Cancer

Cancer has become common in developing countries. According to a study by the International Agency for Research on Cancer, "In the developing world, cancers of the liver, stomach and esophagus were more common, often linked to consumption of carcinogenic preserved foods, such as smoked or salted food, and parasitic infections that attack organs." Lung cancer rates are rising rapidly in poorer nations because of increased use of tobacco. Developed countries "tended to have cancers linked to affluence or a 'Western lifestyle' – cancers of the colon, rectum, breast and prostate – that can be caused by obesity, lack of exercise, diet and age."^[28]

A comprehensive worldwide report, "Food, Nutrition, Physical Activity and the Prevention of Cancer: a Global Perspective", compiled by the World Cancer Research Fund and the American Institute for Cancer Research, reports that there is a significant relation between lifestyle (including food consumption) and cancer prevention. The same report recommends eating mostly foods of plant origin and aiming to meet nutritional needs through diet alone, while limiting consumption of energy-dense foods, red meat, alcoholic drinks and salt and avoiding sugary drinks, processed meat and moldy cereals (grains) or pulses (legumes).

Metabolic syndrome and obesity

Several lines of evidence indicate lifestyle-induced hyperinsulinemia and reduced insulin function (i.e. insulin resistance) as decisive factors in many disease states. For example, hyperinsulinemia and insulin resistance are strongly linked to chronic inflammation, which in turn is strongly linked to a variety of adverse developments such as arterial microinjuries and clot formation (i.e. heart disease) and exaggerated cell division (i.e. cancer).^[29] Hyperinsulinemia and insulin resistance (the so-called metabolic syndrome) are characterized by a combination of abdominal obesity, elevated blood sugar, elevated blood pressure, elevated blood triglycerides, and reduced HDL cholesterol.

Obesity can unfavourably alter hormonal and metabolic status via resistance to the hormone leptin, and a vicious cycle may occur in which insulin/leptin resistance and obesity aggravate one another. The vicious cycle is putatively fuelled by continuously high insulin/leptin stimulation and fat storage, as a result of high intake of strongly insulin/leptin stimulating foods and energy. Both insulin and leptin normally function as satiety signals to the hypothalamus in the brain; however, insulin/leptin resistance may reduce this signal and therefore allow continued overfeeding despite large body fat stores.

There is a debate about how and to what extent different dietary factors – such as intake of processed carbohydrates, total protein, fat, and carbohydrate intake, intake of saturated and trans fatty acids, and low intake of vitamins/minerals – contribute to the development of insulin and leptin resistance. Evidence indicates that diets possibly protective against metabolic syndrome include low saturated and trans fat intake and foods rich in dietary fiber, such as high consumption of fruits and vegetables and moderate intake of low-fat dairy products.^[30]

Hyponatremia

Excess water intake, without replenishment of sodium and potassium salts, leads to hyponatremia, which can further lead to water intoxication at more dangerous levels. A well-publicized case occurred in 2007, when Jennifer Strange died while participating in a water-drinking contest.^[31] More usually, the condition occurs in long-distance endurance events (such as marathon or triathlon competition and training) and causes gradual mental dulling, headache, drowsiness, weakness, and confusion; extreme cases may result in coma, convulsions, and death. The primary damage comes from swelling of the brain, caused by increased osmosis as blood salinity decreases. Effective fluid replacement techniques include Water aid stations during running/cycling races, trainers providing water during team games such as Soccer and devices such as Camel Baks which can provide water for a person without making it too hard to drink the water.

Global nutrition challenges

Death and disability

Non-infectious disease

The most common non-infectious diseases worldwide, that contribute most to the global mortality rate, are cardiovascular diseases, various cancers, diabetes, and chronic respiratory problems, all of which are linked to poor nutrition. Nutrition and diet are closely associated with the leading causes of death, including cardiovascular disease and cancer. Obesity and high sodium intake can contribute to ischemic heart disease, while consumption of fruits and vegetables can decrease the risk of developing cancer. ^[32]

Infectious Disease

The connection between food and sickness is well-established- foodborne and infectious diseases can result in malnutrition, and malnutrition exacerbates infectious disease. Poor nutrition leaves children and adults more susceptible to contracting life threatening diseases such as diarrheal infections and respiratory infections.^[1] According to the WHO, in 2011, 6.9 million children died of infectious diseases like pneumonia, diarrhea, malaria, and neonatal conditions, of which at least one third were associated with undernutrition.^[33][34][35]

Child malnutrition

According to UNICEF, in 2011, 101 million children across the globe were underweight and one in four children, 165 million, were stunted in growth.^[36] Simultaneously, there are 43 million children under five who are overweight or obese. ^[2]Nearly 20 million children under 5 suffer from severe acute malnutrition, a life-threatening condition requiring urgent treatment. ^[2] According to estimations at UNICEF, hunger will be responsible for 5.6 million deaths of children under the age of five this year.^[1] These all represent significant public health emergencies. ^[32] This is because proper maternal and child nutrition has immense consequences for survival, acute and chronic disease incidence, normal growth, and economic productivity of individuals.^[37]

Childhood malnutrition is common and contributes to the global burden of disease.^[38] Childhood is a particularly important time to achieve good nutrition status, because poor nutrition has the capability to lock a child in a vicious cycle of disease susceptibility and recurring sickness, which threatens cognitive and social development.^[1] Undernutrition and bias in access to food and health services leaves children less likely to attend or perform well in school.^[1]

Under nutrition

UNICEF defines under nutrition “as the outcome of insufficient food intake (hunger) and repeated infectious diseases. Under nutrition includes being underweight for one’s age, too short for one’s age (stunted), dangerously thin (wasted), and deficient in vitamins and minerals (micronutrient malnutrient).^[1] Under nutrition causes 53% of deaths of children under five across the world.^[1] It has been estimated that undernutrition is the underlying cause for 35% of child deaths. ^[39] The Maternal and Child Nutrition Study Group estimate that under nutrition, “including fetal growth restriction, stunting, wasting, deficiencies of vitamin A and zinc along with suboptimum breastfeeding- is a cause of 3.1 million child deaths and infant mortality, or 45% of all child deaths in 2011”.^[37]

When humans are undernourished, they no longer maintain normal bodily functions, such as growth, resistance to infection, or have satisfactory performance in school or work.^[1] Major causes of under nutrition in young children include lack of proper breast feeding for infants and illnesses such as diarrhea, pneumonia, malaria, and HIV/AIDS.^[1] According to UNICEF 146 million children across the globe, that one out of four under the age of five, are underweight.^[1] The amount of underweight children has decreased since 1990, from 33 percent to 28 percent between 1990 and 2004.^[1] Underweight and stunted children are more susceptible to infection, more likely to fall behind in school, more likely to become overweight and develop non-infectious diseases, and ultimately earn less than their non-stunted coworkers.^[40] Therefore, undernutrition can accumulate deficiencies in health which results in less productive individuals and societies ^[1]

Many children are born with the inherent disadvantage of low birth weight, often caused by intrauterine growth restriction and poor maternal nutrition, which results in worse growth, development, and health throughout the course of their lifetime. ^[32]Children born at low birthweight (less than 5.5 pounds), are less likely to be healthy and are more susceptible to disease and early death.^[1] Those born at low birthweight also are likely to have a depressed immune system, which can increase their chances of heart disease and diabetes later on in life.^[1] Because 96% of low birthweight occurs in the developing world, low birthweight is associated with being born to a mother in poverty with poor nutritional status that has had to perform demanding labor.^[1]

Stunting and other forms of undernutrition reduces a child’s chance of survival and hinders their optimal growth and health.^[40] Stunting has demonstrated association with poor brain development, which negatively impacts cognitive ability, academic performance, and eventually earning potential. ^[40] Important determinants of stunting include the quality and frequency of infant and child feeding, infectious disease susceptibility, and the mother’s nutrition and health status. ^[40] Undernourished mothers are more likely to birth stunted children, perpetuating a cycle of undernutrition and poverty. ^[40] Stunted children are more likely to develop obesity and chronic diseases upon reaching adulthood. ^[40] Therefore, malnutrition resulting in stunting can further worsen the obesity epidemic, especially in low and middle income countries. ^[40] This creates even new economic and social challenges for vulnerable impoverished groups. ^[40]

Adult overweight and obesity

Malnutrition in industrialized nations is primarily due to excess calories and non-nutritious carbohydrates, which has contributed to the obesity epidemic affecting both developed and some developing nations. ^[41] In 2008, 35% of adults above the age of 20 years old were overweight (BMI 25 kg/m), a prevalence that has doubled worldwide between 1980 and 2008.^[42] Also 10% of men and 14% of women were obese, with an BMI greater than 30. ^[43] Rates of overweight and obesity vary across the globe, with the highest prevalence in the Americas, followed by European nations, where over 50% of the population is overweight or obese. ^[43]

Obesity is more prevalent amongst high income and higher middle income groups than lower divisions of income. ^[43] Women are more likely than men to be obese, where the rate of obesity in women doubled from 8% to 14% between 1980 and 2008. ^[43] Being overweight as a child has become an increasingly important indicator for later development of obesity and non-infectious diseases such as heart disease.^[37] In several western European nations, the prevalence of overweight and obese children rose by 10% from 1980 to 1990, a rate that has began to accelerate recently. ^[1]

Vitamin and mineral malnutrition

Iron deficiency and anemia

Iron deficiency is the most common inadequate nutrient worldwide, affecting approximately 2 billion people.^[44] Globally, anemia affects 1.6 billion people, and represents a public health emergency in children under five and mothers. ^[45] The World Health Organization estimates that there exists 469 million women of reproductive age and approximately 600 million preschool and school-age children worldwide who are anemic.^[46]Anemia, especially iron-deficient anemia, is a critical problem for cognitive developments in children, and its presence leads to maternal deaths and poor brain and motor development in children.^[1] The development of anemia affects mothers and children more because infants and children have higher iron requirements for growth.^[47]Health consequences for iron deficiency in young children include increased perinatal mortality, delayed mental and physical development, negative behavioral consequences, reduced auditory and visual function, and impaired physical performance.^[48] The negative impacts of iron deficiency during child development cannot be reversed and result in reduced academic performance, poor physical work capacity, and decreased productivity in adulthood.^[2] Mothers are also very susceptible to iron-deficient anemia because women lose iron during menstruation, and rarely supplement it in their diet.^[2]Maternal iron deficiency anemia increases the chances of maternal mortality, contributing to at least 18% of maternal deaths in low and middle income countries. ^[49]

Vitamin A deficiency

Vitamin A plays an essential role in developing the immune system in children, therefore, it is considered an essential micronutrient that can greatly affect health.^[1] However, because of the expense of testing for deficiencies, many developing nations have not been able to fully detect and address vitamin A deficiency, leaving vitamin A deficiency considered a silent hunger.^[1] According to estimates, subclinical vitamin A deficiency, characterized by low retinol levels, affects 190 million pre-school children and 19 million mothers worldwide. ^[50] The WHO estimates that 5.2 million of these children under 5 are affected by night blindness, which is considered clinical vitamin A deficiency. ^[51] Severe vitamin A deficiency (VAD) for developing children can result in visual impairments, anemia and weakened immunity, and increase their risk of morbidity and mortality from infectious disease. ^[52] This also presents a problem for women, with WHO estimating that 9.8 million women are affected by night blindness.^[53] Clinical vitamin A deficiency is particularly common among pregnant women, with prevalence rates as high as 9.8% in South-East Asia. ^[50]

Iodine deficiency

Estimates say that 28.5% of the global population is iodine deficient, representing 1.88 billion individuals. ^[54] Although salt iodization programs have reduced the prevalence of iodine deficiency, this is still a public health concern in 32 nations. Moderate deficiencies are common in Europe and Africa, and over consumption is common in the Americas.^[32] Iodine-deficient diets can interfere with adequate thyroid hormone production, which is responsible for normal growth in the brain and nervous system. This ultimately leads to poor school performance and impaired intellectual capabilities.^[1]

Infant and young child feeding

Improvement of breast feeding practices, like early initiation and exclusive breast feeding for the first two years of life, could save the lives of 1.5 million children annually.^[55] Nutrition interventions targeted at young infants aged 0-5 months first encourages early initiation of breastfeeding.^[2] Though the relationship between early initiation of breast feeding and improved health outcomes has not been formally established, a recent study in Ghana suggests a causal relationship between early initiation and reduced infection-caused neo-natal deaths.^[2] Also, experts promote exclusive breastfeeding, rather than using formula, which has shown to promote optimal growth, development, and health of infants.^[56] Exclusive breasfeeding often indicates nutritional status because infants that consume breast milk are more likely to receive all adequate nourishment and nutrients that will aid their developing body and immune system. This leaves children less likely to contract diarrheal diseases and respiratory infections.^[1]

Besides the quality and frequency of breastfeeding, the nutritional status of mothers affects infant health. When mothers do not receive proper nutrition, it threatens the wellness and potential of their children.^[1] Well-nourished women are less likely to experience risks of birth and are more likely to deliver children who will develop well physically and mentally.^[1] Maternal undernutrition increases the chances of low-birth weight, which can increase the risk of infections and asphyxia in fetuses, increasing the probability of neonatal deaths.^[57] Growth failure during intrauterine conditions, associated with improper mother nutrition, can contribute to lifelong health complications.^[2] Approximately 13 million children are born with intrauterine growth restriction annually.^[58]

Undernourishment

Data on global and regional food supply shows that consumption rose from 2011-2012 in all regions. Diets became more diverse, with a decrease in consumption of cereals and roots and an increase in fruits, vegetables, and meat products. ^[59] However, this increase masks the discrepancies between nations, where Africa, in particular, saw a decrease in food consumption over the same years.^[59] This information is derived from food balance sheets that reflect national food supplies, however, this does not necessarily reflect the distribution of micro and macronutrients. ^[59] Often inequality in food access leaves distribution which uneven, resulting in undernourishment for some and obesity for others. ^[59]

Undernourishment, or hunger, according to the FAO, is dietary intake below the minimum daily energy requirement. ^[59] The amount of undernourishment is calculated utilizing the average amount of food available for consumption, the size of the population, the relative disparities in access to the food, and the minimum calories required for each individual. ^[59] According to FAO, 868 million people (12% of the global population) were undernourished in 2012. ^[59] This has decreased across the world since 1990, in all regions except for Africa, where undernourishment has steadily increased. ^[59] However, the rates of decrease are not sufficient to meet the first Millennium Development Goal of halving hunger between 1990 and 2015. ^[59] The global financial, economic, and food price crisis in 2008 drove many people to hunger, especially women and children. The spike in food prices prevented many people from escaping poverty, because the poor spend a larger proportion of their income on food and farmers are net consumers of food. ^[60] High food prices cause consumers to have less purchasing power and to substitute more-nutritious foods with low-cost alternatives. ^[61]

International food insecurity and malnutrition

According to UNICEF, South Asia has the highest levels of underweight children under five, followed by sub-Saharan Africans nations, with Industrialized countries and Latin nations having the lowest rates.^[1]

United States

Nutrition Status

In the United States, 2% of children are underweight, with under 1% stunted and 6% are wasting. ^[1]

Policies

In the US, dietitians are registered (RD) or licensed (LD) with the Commission for Dietetic Registration and the American Dietetic Association, and are only able to use the title "dietitian," as described by the business and professions codes of each respective state, when they have met specific educational and experiential prerequisites and passed a national registration or licensure examination, respectively. In California, registered dietitians must abide by the "Business and Professions Code of Section 2585-2586.8". Anyone may call themselves a nutritionist, including unqualified dietitians, as this term is unregulated. Some states, such as the State of Florida, have begun to include the title "nutritionist" in state licensure requirements. Most governments provide guidance on nutrition, and some also impose mandatory disclosure/labeling requirements for processed food manufacturers and restaurants to assist consumers in complying with such guidance.

In the US, nutritional standards and recommendations are established jointly by the US Department of Agriculture and US Department of Health and Human Services. Dietary and physical activity guidelines from the USDA are presented in the concept of a plate of food which in 2011 superseded the food pyramid that had replaced the Four Food Groups. The Senate committee currently responsible for oversight of the USDA is the Agriculture, Nutrition and Forestry Committee. Committee hearings are often televised on C-SPAN.

The U.S. Department of Health and Human Services provides a sample week-long menu which fulfills the nutritional recommendations of the government.^[62] Canada's Food Guide is another governmental recommendation.

Industrialized countries

According to UNICEF, the Commonwealth of Independent States has the lowest rates of stunting and wasting, at 14 percent and 3 percent.^[1] The nations of Estonia, Finland, Iceland, Lithuania and Sweden have the lowest prevalence of low birthweight children in the world- at 4%.^[1] Proper prenatal nutrition is responsible for this small prevalence of low birthweight infants.^[1] However, low birthweight rates are increasing, due to the use of fertility drugs, resulting in multiple births, women bearing children at an older age, and the advancement of technology allowing more pre-term infants to survive. ^[1] Industrialized nations more often face malnutrition in the form of over-nutrition from excess calories and non-nutritious carbohydrates, which has contributed greatly to the public health epidemic of obesity. ^[41] Disparities, according to gender, geographic location and socio-economic position, both within and between countries, represent the biggest threat to child nutrition in industrialized countries. These disparities are a direct product of social inequalities and social inequalities are rising throughout the industrialized world, particularly in Europe.^[1]

South Asia

South Asia has the highest percentage and number of underweight children under five in the world, at approximately 78 million children.^[1] Patterns of stunting and wasting are similar, where 44% have not reached optimal height and 15% are wasted, rates much higher than any other regions.^[1] This region of the world has extremely high rates of child underweight- 46% of its child population under five is underweight. ^[1] India, Bangladesh, and Pakistan alone account for half the globe’s underweight child population. ^[1] South Asian nations have made progress towards the MDGs, considering the rate has decreased from 53% since 1990, however, a 1.7% decrease of underweight prevalence per year will not be sufficient to meet the 2015 goal. ^[1] Some nations, such as Afghanistan, Bangladesh, and Sri Lanka, on the other hand, have made significant improvements, all decreasing their prevalence by half in ten years. ^[1] While India and Pakistan have made modest improvements, Nepal has made no significant improvement in underweight child prevalence. ^[1] Other forms of undernutrition have continued to persist with high resistance to improvement, such as the prevalence of stunting and wasting, which has not changed significantly in the past 10 years. ^[1] Causes of this poor nutrition include energy-insufficient diets, poor sanitation conditions, and the gender disparities in educational and social status. ^[1] Girls and women face discrimination especially in nutrition status, where South Asia is the only region in the world where girls are more likely to be underweight than boys.^[1] In South Asia, 60% of children in the lowest quintile are underweight, compared to only 26% in the highest quintile, and the rate of reduction of underweight is slower amongst the poorest. ^[63]

Eastern/South Africa

The Eastern and Southern African nations have shown no improvement since 1990 in the rate of underweight children under five.^[1] They have also made no progress in halving hunger by 2015, the most prevalent Millennium Development Goal.^[1] This is due primarily to the prevalence of famine, declined agricultural productivity, food emergencies, drought, conflict, and increased poverty.^[1] This, along with HIV/AIDS, has inhibited the nutrition development of nations such as Lesotho, Malawi, Mozambique, Swaziland, Zambia and Zimbabwe.^[1] Botswana has made remarkable achievements in reducing underweight prevalence, dropping 4% in 4 years, despite its place as the second leader in HIV prevalence amongst adults in the globe.^[1] South Africa, the wealthiest nation in this region, has the second lowest proportion of underweight children at 12%, but hs been steadily increasing in underweight prevalence since 1995.^[1] Almost half of Ethiopian children are underweight, and along with Nigeria, they account for almost one-third of the underweight under five in all of Sub-Saharan Africa.^[1]

West/Central Africa

West/Central Africa has the highest rate of children under five underweight in the world.^[1] Of the countries in this region, the Congo has the lowest rate at 14%, while the nations of Democratic Republic of the Congo, Ghana, Guinea, Mali, Nigeria, Senegal and Togo are improving slowly.^[1] In Gambia, rates decreased from 26% to 17% in four years, and their coverage of vitamin A supplementation reaches 91% of vulnerable populations.^[1] This region has the next highest proportion of wasted children, with 10% of the population under five not at optimal weight.^[1] Little improvement has been made between the years of 1990 and 2004 in reducing the rates of underweight children under five, whose rate stayed approximately the same.^[1] Sierra Leone has the highest child under five mortality rate in the world, due predominantly to its extreme infant mortality rate, at 238 deaths per 1000 live births.^[1] Other contributing factors include the high rate of low birthweight children (23%) and low levels of exclusive breast feeding (4%).^[1] Anemia is prevalent in these nations, with unacceptable rates of iron deficient anemia.^[1] The nutritional status of children is further indicated by its high rate of child wasting - 10%.^[1] Wasting is a significant problem in Sahelian countries – Burkina Faso, Chad, Mali, Mauritania and Niger – where rates fall between 11% and 19% of under fives, affecting more than 1 million children.^[1]

Middle East/North Africa

Six countries in the Middle East and North Africa region are on target to meet goals for reducing underweight children by 2015, and 12 countries have prevalence rates below 10%.^[1] However, the nutrition of children in the region as a whole has degraded for the past ten years due to the increasing portion of underweight children in three populous nations – Iraq, Sudan, and Yemen.^[1] Forty six percent of all children in Yemen are underweight, a percentage that has worsened by 4% since 1990.^[1] In Yemen, 53% of children under five are stunted and 32% are born at low birth weight.^[1] Sudan has an underweight prevalence of 41%, and the highest proportion of wasted children in the region at 16%.^[1] One percent of households in Sudan consume iodized salt.^[1] Iraq has also seen an increase in child underweight since 1990.^[1] Djibouti, Jordan, the Occupied Palestinian Territory (OPT), Oman, the Syrian Arab Republic and Tunisia are all projected to meet minimum nutrition goals, with OPT, Syrian AR, and Tunisia the fastest improving regions.^[1] This region demonstrates that undernutrition does not always improve with economic prosperity, where the United Arab Emirates, for example, despite being a wealthy nation, has similar child death rates due to malnutrition to those seen in Yemen.^[1]

East Asia/Pacific

The East Asia/Pacific region has reached its goals on nutrition, in part due to the improvements contributed by China, the region’s most populous country.^[1] China has reduced its underweight prevalence from 19 percent to 8 percent between 1990 and 2002. ^[1] China played the largest role in the world in decreasing the rate of children under five underweight between 1990 and 2004, halving the prevalence.^[1] This reduction of underweight prevalence has aided in the lowering of the under 5 mortality rate from 49 to 31 of 1000. They also have a low birthweight rate at 4%, a rate comparable to industrialized countries, and over 90% of households receive adequate iodized salts.^[1] However, large disparities exist between children in rural and urban areas, where 5 provinces in China leave 1.5 million children iodine deficient and susceptible to diseases.^[1] Singapore, Vietnam, Malaysia, and Indonesia are all projected to reach nutrition MDGs. ^[1] Singapore has the lowest under five mortality rate of any nation, besides Iceland, in the world, at 3%.^[1] Cambodia has the highest rate of child mortality in the region (141 per 1,000 live births), while still its proportion of underweight children increased by 5 percent to 45% in 2000. Further nutrient indicators show that only 12 per cent of Cambodian babies are exclusively breastfed and only 14 per cent of households consume iodized salt.^[1]

Latin America/Caribbean

This region has undergone the fastest progress in decreasing poor nutrition status of children in the world.^[1] The Latin American region has reduced underweight children prevalence by 3.8% every year between 1990 and 2004, with a current rate of 7% underweight.^[1] They also have the lowest rate of child mortality in the developing world, with only 31 per 1000 deaths, and the highest iodine consumption.^[1] Cuba has seen improvement from 9 to 4 percent underweight under 5 between 1996 and 2004.^[1] The prevalence has also decreased in the Dominican Republic, Jamaica, Peru, and Chile.^[1] Chile has a rate of underweight under 5, at merely 1%.^[1] The most populous nations, Brazil and Mexico, mostly have relatively low rates of underweight under 5, with only 6% and 8%.^[1] Guatemala has the highest percentage of underweight and stunted children in the region, with rates above 45%.^[1] There are disparities amongst different populations in this region. For example, children in rural areas have twice the prevalence of underweight at 13%, compared to urban areas at 5%.^[1]

Nutrition Access Disparities

Socioeconomic status

In all regions of the world, lack of proper nutrition is both a consequence and cause of poverty.^[1] Internationally, impoverished individuals are less likely to have access to nutritious food, and are more vulnerable to struggle harder to come out of poverty than those who have healthy diets.^[1] Disparities in socieo-economic status, between and within nations, provide the largest threat to child nutrition in industrialized nations, where social inequality is on the rise. ^[64] According to UNICEF, children living in the poorest households are twice as likely to be underweight as those in the richest.^[1] Those in the lowest wealth quintile and whose mothers have the least education demonstrate the highest rates of child mortality and stunting. ^[65] Throughout the developing world, socioeconomic inequality in childhood malnutrition is more severe than in upper income brackets, regardless of the general rate of malnutrition. ^[66] Concurrently, the greatest increase in childhood obesity has been seen in the lower middle income bracket.^[43]

Location

Rural populations

According to UNICEF, children in rural locations are more than twice as likely to be underweight as compared to children under five in urban areas.^[1] In Latin American/Caribbean nations, “Children living in rural areas in Bolivia, Honduras, Mexico and Nicaragua are more than twice as likely to be underweight as children living in urban areas. That likelihood doubles to four times in Peru.” ^[1]

Urban populations

Minorities

In the United States, the incidence of low birthweight is on the rise amongst all populations, but particularly amongst minorities. ^[67]

Special needs

Gender

According to UNICEF, boys and girls have almost identical rates of underweight children under 5 across the world, except for in South Asia.^[1]

Food and Nutrition Policy and Programs

Nutrition interventions

Nutrition directly influences progress towards meeting the Millennium Goals of eradicating hunger and poverty through health and education.^[1] Therefore, nutrition interventions take a multi-faceted approach to improve the nutrition status of various populations. Policy and programming must target both individual behavioral changes and policy approaches to public health. While most nutrition interventions focus on delivery through the health-sector, non-health sector interventions targeting agriculture, water and sanitation, and education are important as well.^[2] Global nutrition micro-nutrient deficiencies often receive large-scale solution approaches by deploying large governmental and non-governmental organizations. For example, in 1990, iodine deficiency was particularly prevalent, with one in five households, or 1.7 billion people, not consuming adequate iodine, leaving them at risk to develop associated diseases. ^[1] Therefore, a global campaign to iodize salt to eliminate iodine deficiency successfully boosted the rate to 69% of households in the world consuming adequate amounts of iodine.^[1]

Emergencies and crises often exacerbate undernutrition, due to the aftermath of crises that include food insecurity, poor health resources, unhealthy environments, and poor healthcare practices.^[1] Therefore, the repercussions of natural disasters and other emergencies can exponentially increase the rates of macro and micronutrient deficiencies in populations.^[1]Disaster relief interventions often take a multi-faceted public health approach. UNICEF’s programming targeting nutrition services amongst disaster settings include nutrition assessments, measles immunization, vitamin A supplementation, provision of fortified foods and micronutrient supplements, support for breastfeeding and complementary feeding for infants and young children, and therapeutic and supplementary feeding.^[1] For example, during Nigeria’s food crisis of 2005, 300,000 children received therapeutic nutrition feeding programs through the collaboration of UNICEF, the Niger government, the World Food Programme, and 24 NGOs utilizing community and facility based feeding schemes.^[1]

Interventions aimed at pregnant women, infants, and children take a behavioral and program-based approach. Behavioral intervention objectives include promoting proper breast-feeding, the immediate initiation of breastfeeding, and its continuation through 2 years and beyond.^[2] UNICEF recognizes that to promote these behaviors, healthful environments must be established conducive to promoting these behaviors, like healthy hospital environments, skilled health workers, support in the public and workplace, and removing negative influences.^[2] Finally, other interventions include provisions of adequate micro and macro nutrients such as iron, anemia, and vitamin A supplements and vitamin-fortified foods and ready-to-use products.^[2] Programs addressing micro-nutrient deficiencies, such as those aimed at anemia, have attempted to provide iron supplementation to pregnant and lactating women. However, because supplementation often occurs too late, these programs have had little impact.^[1] Interventions such as women’s nutrition, early and exclusive breastfeeding, appropriate complementary food and micronutrient supplementation have proven to reduce stunting and other manifestations of undernutrition. ^[40] A Cochrane review of community-based maternal health packages showed that this community-based approach had a positive impact on the initiation of breastfeeding within one hour of birth.^[68] Some programs have had adverse effects. One example is the “Formula for Oil” relief program in Iraq, which resulted in the replacement of breastfeeding for formula, which has negatively affected infant nutrition. ^[1]

Implementation and delivery platforms

In April 2010, the World Bank and the IMF released a policy briefing entitled “Scaling up Nutrition (SUN): A Framework for action” that represented a partnered effort to address the Lancet’s Series on under nutrition, and the goals it set out for improving under nutrition.^[69] They emphasized the 1000 days after birth as the prime window for effective nutrition intervention, encouraging programming that was cost-effective and showed significant cognitive improvement in populations, as well as enhanced productivity and economic growth.^[69] This document was labeled the SUN framework, and was launched by the UN General Assembly in 2010 as a road map encouraging the coherence of stakeholders like governments, academia, UN system organizations and foundations in working towards reducing under nutrition.^[69] The SUN framework has initiated a transformation in global nutrition- calling for country-based nutrition programs, increasing evidence based and cost–effective interventions, and “integrating nutrition within national strategies for gender equality, agriculture, food security, social protection, education, water supply, sanitation, and health care”.^[69] Government often plays a role in implementing nutrition programs through policy. For instance, several East Asian nations have enacted legislation to increase iodization of salt to increase household consumption. ^[1] Political commitment in the form of evidence-based effective national policies and programs, trained skilled community nutrition workers, and effective communication and advocacy can all work to decrease malnutrition. ^[40] Market and industrial production can play a role as well. For example, in the Philippines, improved production and market availability of iodized salt increased household consumption. ^[1] While most nutrition interventions are delivered directly through governments and health services, other sectors, such as agriculture, water and sanitation, and education, are vital for nutrition promotion as well.^[2]

Nutrition Education

Nutrition is taught in schools in many countries. In England and Wales the Personal and Social Education and Food Technology curricula include nutrition, stressing the importance of a balanced diet and teaching how to read nutrition labels on packaging. In many schools a Nutrition class will fall within the Family and Consumer Science or Health departments. In some American schools, students are required to take a certain number of FCS or Health related classes. Nutrition is offered at many schools, and if it is not a class of its own, nutrition is included in other FCS or Health classes such as: Life Skills, Independent Living, Single Survival, Freshmen Connection, Health etc. In many Nutrition classes, students learn about the food groups, the food pyramid, Daily Recommended Allowances, calories, vitamins, minerals, malnutrition, physical activity, healthy food choices and how to live a healthy life.

A 1985 US National Research Council report entitled Nutrition Education in US Medical Schools concluded that nutrition education in medical schools was inadequate.^[70] Only 20% of the schools surveyed taught nutrition as a separate, required course. A 2006 survey found that this number had risen to 30%.^[71]

History

Humans have evolved as omnivorous hunter-gatherers over the past 250,000 years. The diet of early modern humans varied significantly depending on location and climate. The diet in the tropics tended to be based more heavily on plant foods, while the diet at higher latitudes tended more towards animal products. Analysis of postcranial and cranial remains of humans and animals from the Neolithic, along with detailed bone modification studies have shown that cannibalism was also prevalent among prehistoric humans.^[72]

Agriculture developed about 10,000 years ago in multiple locations throughout the world, providing grains such as wheat, rice, maize, and potatoes, with staples such as bread, pasta, and tortillas. Farming also provided milk and dairy products, and sharply increased the availability of meats and the diversity of vegetables. The importance of food purity was recognized when bulk storage led to infestation and contamination risks. Cooking developed as an often ritualistic activity, due to efficiency and reliability concerns requiring adherence to strict recipes and procedures, and in response to demands for food purity and consistency.^[73]

From antiquity to 1900

Around 3000 BC the Vedic texts had mentions of scientific research on nutrition.

The first recorded nutritional experiment is found in the Bible's Book of Daniel. Daniel and his friends were captured by the king of Babylon during an invasion of Israel. Selected as court servants, they were to share in the king's fine foods and wine. But they objected, preferring vegetables (pulses) and water in accordance with their Jewish dietary restrictions. The king's chief steward reluctantly agreed to a trial. Daniel and his friends received their diet for 10 days and were then compared to the king's men. Appearing healthier, they were allowed to continue with their diet.^[74]

Around 475 BC, Anaxagoras stated that food is absorbed by the human body and therefore contained "homeomerics" (generative components), suggesting the existence of nutrients.^[73] Around 400 BC, Hippocrates said, "Let food be your medicine and medicine be your food."^[75]

In the 16th century, scientist and artist Leonardo da Vinci compared metabolism to a burning candle. In 1747, Dr. James Lind, a physician in the British navy, performed the first scientific nutrition experiment, discovering that lime juice saved sailors who had been at sea for years from scurvy, a deadly and painful bleeding disorder. The discovery was ignored for forty years, after which British sailors became known as "limeys." The essential vitamin C within lime juice would not be identified by scientists until the 1930s.

Around 1770, Antoine Lavoisier, the "Father of Nutrition and Chemistry" discovered the details of metabolism, demonstrating that the oxidation of food is the source of body heat. In 1790, George Fordyce recognized calcium as necessary for fowl survival. In the early 19th century, the elements carbon, nitrogen, hydrogen and oxygen were recognized as the primary components of food, and methods to measure their proportions were developed.

In 1816, François Magendie discovered that dogs fed only carbohydrates and fat lost their body protein and died in a few weeks, but dogs also fed protein survived, identifying protein as an essential dietary component.^{[citation needed]} In 1840, Justus Liebig discovered the chemical makeup of carbohydrates (sugars), fats (fatty acids) and proteins (amino acids). In the 1860s, Claude Bernard discovered that body fat can be synthesized from carbohydrate and protein, showing that the energy in blood glucose can be stored as fat or as glycogen.

In the early 1880s, Kanehiro Takaki observed that Japanese sailors (whose diets consisted almost entirely of white rice) developed beriberi (or endemic neuritis, a disease causing heart problems and paralysis) but British sailors and Japanese naval officers did not. Adding various types of vegetables and meats to the diets of Japanese sailors prevented the disease.

In 1896, Baumann observed iodine in thyroid glands. In 1897, Christiaan Eijkman worked with natives of Java, who also suffered from beriberi. Eijkman observed that chickens fed the native diet of white rice developed the symptoms of beriberi, but remained healthy when fed unprocessed brown rice with the outer bran intact. Eijkman cured the natives by feeding them brown rice, discovering that food can cure disease. Over two decades later, nutritionists learned that the outer rice bran contains vitamin B₁, also known as thiamine.

From 1900 to the present

In the early 20th century, Carl von Voit and Max Rubner independently measured caloric energy expenditure in different species of animals, applying principles of physics in nutrition. In 1906, Wilcock and Hopkins showed that the amino acid tryptophan was necessary for the survival of rats. He fed them a special mixture of food containing all the nutrients he believed were essential for survival, but the rats died. A second group of rats to which he also fed an amount of milk containing vitamins.^[76] Gowland Hopkins recognized "accessory food factors" other than calories, protein and minerals, as organic materials essential to health but which the body cannot synthesize. In 1907, Stephen M. Babcock and Edwin B. Hart conducted the single-grain experiment. This experiment ran through 1911.

In 1912, Casimir Funk coined the term vitamin, a vital factor in the diet, from the words "vital" and "amine," because these unknown substances preventing scurvy, beriberi, and pellagra, were thought then to be derived from ammonia. The vitamins were studied in the first half of the 20th century.

In 1913, Elmer McCollum discovered the first vitamins, fat soluble vitamin A, and water soluble vitamin B (in 1915; now known to be a complex of several water-soluble vitamins) and named vitamin C as the then-unknown substance preventing scurvy. Lafayette Mendel and Thomas Osborne also performed pioneering work on vitamins A and B. In 1919, Sir Edward Mellanby incorrectly identified rickets as a vitamin A deficiency, because he could cure it in dogs with cod liver oil.^[77] In 1922, McCollum destroyed the vitamin A in cod liver oil but found it still cured rickets, and named it vitamin D. Also in 1922, H.M. Evans and L.S. Bishop discovered vitamin E as essential for rat pregnancy, and originally called it "food factor X" until 1925.

In 1925, Hart discovered that trace amounts of copper are necessary for iron absorption. In 1927, Adolf Otto Reinhold Windaus synthesized vitamin D, for which he won the Nobel Prize in Chemistry in 1928. In 1928, Albert Szent-Györgyi isolated ascorbic acid, and in 1932 proved that it is vitamin C by preventing scurvy. In 1935 he synthesized it, and in 1937 won a Nobel Prize for his efforts. Szent-Györgyi concurrently elucidated much of the citric acid cycle.

In the 1930s, William Cumming Rose identified essential amino acids, necessary protein components which the body cannot synthesize. In 1935, Underwood and Marston independently discovered the necessity of cobalt. In 1936, Eugene Floyd Dubois showed that work and school performance are related to caloric intake. In 1938, Erhard Fernholz discovered the chemical structure of vitamin E. It was synthesised by Paul Karrer.

In 1940, rationing in the United Kingdom during and after World War II took place according to nutritional principles drawn up by Elsie Widdowson and others. In 1941, the first Recommended Dietary Allowances (RDAs) were established by the National Research Council.

In 1992, The U.S. Department of Agriculture introduced the Food Guide Pyramid. In 2002, a Natural Justice study showed a relation between nutrition and violent behavior. In 2005, a study found that obesity may be caused by adenovirus in addition to bad nutrition.^[78]

See also

Further reading

• Curley, S., and Mark (1990). The Natural Guide to Good Health, Lafayette, Louisiana, Supreme Publishing
• Galdston, I. (1960). Human Nutrition Historic and Scientific. New York: International Universities Press. 
• Hirschfelder, Gunther / Trummer, Manuel (2013). Food and Drink. Leibniz Institute of European History (IEG). 
• Mahan, L.K. and Escott-Stump, S. eds. (2000). Krause's Food, Nutrition, and Diet Therapy (10th ed.). Philadelphia: W.B. Saunders Harcourt Brace. ISBN 0-7216-7904-8. 
• Human Nutrition. Readings from Scientific American. San Francisco: W.H. Freeman & Co. 1978. ISBN 0-7167-0183-9 
• Thiollet, J.-P. (2001). Vitamines & minéraux. Paris: Anagramme. 
• Willett, Walter C.; Stampfer, Meir J. (2003). "Rebuilding the Food Pyramid". Scientific American 288 (1): 64–71. doi:10.1038/scientificamerican0103-64. PMID 12506426. 

References

External links

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• Diet, Nutrition and the prevention of chronic diseases by a Joint WHO/FAO Expert consultation (2003)
• United States Department of Agriculture (USDA) Frequently asked questions
• Understanding the choices - Health Journey
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